SOAP Notes

In medical school, one of the last mysteries to be addressed prior to being allowed to work on the wards was the hoary topic of how to write up a patient interaction.  I remember being mystified as to the meaning of the term “SOAP Note” and even when it was explained to me, I truly didn’t understand what was the big deal.  Now that I have been in practice for a while, I appreciate the simplicity and richness of this basic idea.  Medicine has the advantage of being a very old practice, with problems that are often life and death but which are finite.  The systems we use to identify, evaluate, investigate, diagnose and treat patients’ problems must be flexible, robust and infinitely applicable.

Subjective

The ’S’ in SOAP stands for subjective.  This is a description of the problem from the patient’s point of view.  Their chief complaint (CC) is the topic, and a skilled practitioner solicits details such as when did the problem start?  Are there things that make it better or worse?  What has the patient tried already to remedy the problem?  Is it generally improving or generally worsening?  There are innumerable acronyms to remember the questions to ask; the one taught in my training was OLDCAR – Onset, Location, Duration, Character, Associated/Alleviating/Aggravating, Radiation.  We were also coached that using open ended questions to start with and allowing patients to talk for at least thirty seconds without interrupting them would yield satisfied patients who felt heard.

As the patient’s narrative winds down, it’s time to pull out diagnostic acumen and ask more specific questions to try to establish the likely cause of the problem and create what we call a differential diagnosis, which is a list of possible causes of the patient’s symptoms, usually including the most likely but also the few possibly dangerous ones.

I think this practice could be easily adapted to other workplaces, and even to parenting.  Imagine a child who is complaining that they are bored.  Our instinctive reaction would be to suggest, sarcastically, that we have a kitchen that needs cleaning if they are so bored, or to tell them to go for a walk outside and get some fresh air.  The problem with offering solutions or plans (the ‘P’ in SOAP) at this point is that we actually just have the chief complaint.  We have not explored the child’s subjective impression of their problem.  How long have they been bored?  What are they feeling in their body which makes them believe that they are bored?  What have they tried to alleviate the boredom?  Are there any thoughts or interactions they have had recently that are making the boredom better or worse?  Are they bored all the time or does the boredom come and go (Character)?  By the time you have finished this explication of their boredom, you and they will likely have some ideas for plans which are more respectful of the child’s experience of boredom and thus much more likely to address it.

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