The SOAP (subjective, objective, assessment, and plan) note is one of the most commonly used forms of documentation in the healthcare industry today. Changing needs and increasing complexity in medical care have prompted questions about SOAP’s ongoing relevance.
With the appropriate EHR integration, SOAP remains useful for current healthcare needs.
History and Origins of the SOAP Note
In the early 20th century, there was no standard for health documentation. Dr. Lawrence Weed sought to create a more disciplined method for recording patient data.
Weed first developed problem-oriented medical records (POMR) in the 1950s. His revolutionary way of recording and monitoring patient information helped providers and facilities communicate more efficiently and keep more organized patient data. Weed’s POMR system evolved into the modern SOAP note.
How to Use SOAP Notes
The acronym SOAP involves the steps that providers should follow for entering patient data, starting from their first encounter with the patient.
1. Subjective: The Subjective step is how the patient describes their condition and reason for seeking care. This may include struggles with substance abuse or feelings of depression. The clinician should note all symptoms mentioned, as well as medical history, family health history, and changes in functioning.
2. Objective: This step includes specific measurements, test results, and exam findings. It may include current medications and other treatments. The clinician should include any changes from previous tests, if applicable.
3. Assessment: This section combines the previous two to establish a diagnosis. It may include a differential diagnosis if the patient’s condition changes or there is no specific diagnosis.
4. Plan: This section includes the clinician’s plan for treatment. This may include referrals or medication-assisted treatment (MAT). The plan should also include specific goals and scheduled follow-ups.
SOAP information helps improve quality of care and justifies a clinician’s charges in a third-party payer audit.
Current Concerns About SOAP Notes
Some clinicians have suggested changing SOAP to APSO, speeding up ongoing care and reducing the time needed to find the assessment and plan. Others have argued, however, that the APSO order could make a patient’s input appear less important. It may also make a clinician less inclined to conduct more thorough examinations.
Another concern about the use of the SOAP note is that it does not explicitly state where to record changes over time. Behavioral health and addiction treatment often involve complex conditions treated over the course of months or years. With the right EHR, however, SOAP notes can easily incorporate changes to a patient’s condition, treatment, and goals.
Including SOAP Notes in EHR
Including SOAP templates in a behavioral health EHR has numerous benefits. For example, BestNotes EHR solution provides:
Greater efficiency by eliminating double data entry
Autopopulating data from the EHR’s treatment plan section, such as diagnosis, goals, and interventions
Ability to review historical SOAP notes
Incorporate data points that make up the Golden Thread
Incorporate data from Outcome Measures
An EHR that supports SOAP
As an addiction treatment and behavioral health provider, your clients have complex needs. Your best EHR option is tailored to those unique needs.
BestNotes EHR offers progress notes, medication management, and a host of other features that improve your care while reducing costs. Contact us today to find out more, and try us out for free!