Tuesday, January 23, 2018

The Singing Pen of Doctor Jen: In defense of SOAP notes

The Singing Pen of Doctor Jen: In defense of SOAP notes: Our hospital system's IT department has recently encouraged us all to change our default encounter note template from the traditional &q...

Hi Jen:

Never been a fan of SOAP notes but our templates both in and out patient follow that format, however the A/P are lumped together.  The S is also problematic, as patients are often here for nothing that really has an S like an incedentaloma on an imaging study, though they do have pertinent negaitives. 

Interestingly, now that we have PDOCS for consults and Dragon Dictation, I find myself doing consults with Stephen Covey's sage advice "Begin with the end in mind."  I will list the problems, dictate the analysis and solutions, the go back to page 1 and dictate the HPI, copy and paste the pertinent lab in the lab section, then click what's needed for past history, ROS and exam, with a few phrase dictations where needed.  What's different between my note and our residents' output is that mine has no fake news.  If I didn't ask about dyspareunia, which I don't, it is left blank.  My patients with prostheses never have pulses in them, and if a thyroid is palpable there is a description of that.  Where we lose out in the EMR seems to be in the copy/paste which saves time but propagates falsehood.