Communication is the most important thing that doctors do. It is how medications are ordered, how patients are educated, and how procedures are performed. Doctors talk to patients, nurses, social workers, counselors, physical therapists, occupational therapists, and medical assistants constantly. Effective communication is the key to getting things done in the hospital.
But how do doctors communicate with each other? How does a general practitioner communicate with a specialist, and how do specialists communicate between specialties? Despite what many people think, doctors talk all the time, but not in a conventional way. Rarely do doctors talk about patients exclusively over the phone or via email. Only in the hospital do specialists speak face to face. And usually these conversations are quick and dirty, and do not give the full picture. As a medical student, patients often ask me “why won’t my specialist just call my GP?” or vise-versa.
The reason why doctors typically don’t call other doctors is because verbal communication is one of the least effective ways to talk about a patient. Imagine you a doctor taking care of 15 patients simultaneously. You are tired, probably over-worked, and really want to go on your lunch break. Would you remember a 10-minute phone conversation about a complex patient? How long would it take for you to forget the finer details? What if things change? Are you ok with receiving and making calls every 20 minutes? Now multiply these issues for the 15 other patients you have and you will quickly realize how impractical verbal communication is. So how do doctors communicate?
Medical notes are the pinnacle of healthcare communication. Though they may be the bane or many residents existence, they are vital to communicating with other doctors and the inter-professional team. Medical notes are static manifestations of a healthcare providers thought process at any given time. They capture a snapshot of what that provider was thinking in the moment. Furthermore, medical notes are written in a specific way which makes them an elegant and efficient form of communication.
Subjective, objective, assessment and plan. These 4 elements make up the SOAP note, the most efficient form of medical communication. SOAP is powerful because it allows doctors to write their thought process in a way that others can easily follow. It is a way for physicians to not only share their conclusions, but also how they came to those conclusions. It’s beautiful because it follows the natural flow of every patient encounter in a succinct way. Patients also benefit because, if they know how to decode the note, they also know how to effectively take charge of their care. So do you decode the SOAP note? Lets break down each section and explore it’s meaning.
According to the Merriam-Webster Dictionary, subjective is defined as “characteristic of or belonging to reality as perceived rather than as independent of mind.” In the context of clinical medicine, this is essentially the patients story of what happened. Doctors only include the patients story here, because it gives the reader a snapshot of the patient at the time of the visit. This allows the reader to see what the doctor would have seen at that moment, and to hopefully draw similar conclusions.
The subjective portion of SOAP notes can take many forms. Most of the time, they start with an identification (ID) statement. This statement simply identifies the patient. ID statements always have the same structure, which goes something like the following:
“[Patient’s name] is a [age, sex] with [pertinent chronic conditions] presenting to the [clinic /hospital/emergency department] with a [length of present illness] of [modifiers] [problem]”
A real-life example would be:
“Jane Doe is a 46 year old female with chronic high blood pressure presenting to the clinic with a 3 week history of mild, right temporal headache.”
This structure succinctly gives all the pertinent introductory information so that the reader can become acquainted with the patient and their medical history. Just as introductions are important in face-to-face conversations, so too are they necessary for clinical notes.
The objective portion of the note includes the vital signs, physical exam findings, and pertinent labs/imaging. Ideally, they will be in that order. Vitals are given first because abnormal findings here may influence the physical exam. The physical exam is given before the lab findings because the physical exam may influence what labs or imaging is performed.
Even though this line of cause and affect does not always pan out in the clinic, it is still written the same way so that the reader is guided through the clinical reasoning process.
The assessment is the portion of the note where a doctor takes all of the subjective and objective information and interprets it. It starts with the assessment statement, then goes on to further explain the thought process of the healthcare provider.
The assessment statement is typically a one sentence summary that ends with what the doctor thinks is going on. It should re-identify the patient and provide the evidence for a diagnosis or differential diagnosis (list of possible but unconfirmed diagnoses based on the subjective and objective information). Because the reader is now more familiar with the patient, the ID statement can be shortened to include only pertinent information (i.e. information that supports the assessment). The second and third sentences further support the assessment, and summarizes the clinical reasoning process. If the patient’s diagnosis is confirmed, a differential diagnosis may not be necessary. The following is an example:
“[Patient name] is a [age, sex] with a history of [pertinent history supporting the diagnosis] now with [subjective and objective findings supporting diagnosis/differential diagnosis] concerning for [diagnosis/differential diagnosis].”
If the diagnosis is not confirmed, the physician would go on to say:
“[X diagnosis] is most likely because [pertinent positive or negative findings supporting X diagnosis].”
A real-life assessment may look like the following:
“Jane Doe is a 46 year old female with a 3 week history of mild, persistent, right temporal headache that worsens with stress and improves with NSAIDs, concerning for tension headache vs migraine. Tension headache is most likely because the headache is worse with stress and at the end of the day, is alleviated with NSAIDs, and is not associated with an aura or increased sensitivity to light or sounds. However, the headache is also unilateral to the right temporal region, consistent with migraines.
Sometimes, physicians will include more information describing the hospital course, what treatments have or haven’t been tried, and if the patient is improving or worsening. A simple assessment of “doing better/worse” is simple but invaluable for the reader.
The plan is exactly what it sounds like, a plan to treat the patient. It is usually organized according to the problem list. A problem list is a list of problems that a patient has. The most important (IE serious) problem is given first, followed by the second problem and so-on. The following is an example of a plan:
- Headaches concerning for Tension headaches
- Counselled patient on stress management
- Counselled patient on NSAID over-use headaches
- Counselled patient on hydration
- Use NSAIDs PRN
- Return to clinic if headaches worsen or become associated with neurological symptoms
The plan is often the most variable part of the note, and is highly influenced by a physicians or departments stylistic choices. Despite this, it should be one of the most simple parts of the note for lay-readers to understand. If you do not understand a portion of the Plan, patients should feel empowered to ask their doctors to explain.
The reason why doctors don’t call each other is because it is not effective. Instead, doctors use SOAP notes to effectively explain their clinical reasoning. SOAP is beautiful because it allows the reader to follow the diagnostic process, in a way that is not possible verbally. The best SOAP notes are relatively short, and easy to read and follow.
With the advent of the internet, patients are now more than ever empowered to review their own charts and see what their doctors think. SOAP notes can seem complicated to laypeople, but they will almost always follow the above format and will always give the clinical reasoning process. Hopefully this article has de-mystified the SOAP note and allow you to read or write one yourself.
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