Guidelines for SOAP (Post Encounter Notes)

Introduction: "If it ain't written down, it didn't happen"

Expect intense feedback on your standardized patient SOAP (PEN) notes.  The reasons for this include:

• Good notes are essential in primary care to document changes over time that can be crucial to diagnosis and management
• Thinking about the note ahead of time can improve the patient encounter
• Notes are legal documents that are taken as the formal, complete record of the encounter. (The lawyers and insurance companies don't believe that additional things happened during the encounter - and going back to change a note is regarded as very suspicious of fraud.)
• Students consistently gather significant amounts of important information during the encounter they don't enter in the note.
• The note accounts for half of the Integrated Clinical Encounter (ICE) score on USMLE-Step 2 CS- and practice improves your notes
• Students who incorporate feedback from have significantly higher scores on the CSA.

Notes improve dramatically if you work at developing this core clinical skill. We use formats very similar to those of USMLE so this experience should help significantly with that exam. Even better, an organized approach to notes REALLY helps in practice, especially when you are most rushed and/or perplexed by a case. The note helps to organize the data, illustrate what items are missing, and prompt clinical reasoning. Even if the case cannot be resolved immediately, a complete and reliable baseline facilitates diagnosis and/or management as the clinical picture evolves - it makes your future work (or that of any subsequent physician) much easier.

Strong Hints: (based on feedback from students and faculty)

1. Practice talking to patients in order to collect all pertinent data for each section at the same time.  This will aid in a smooth transition between sections. Look at your videos and practice, practice, practice until you have comfortable phrases and sets of questions that work well for you.
2. As you finish the patient encounter "think SOAP note". Mentally scan the expected SOAP note sections and check you have all the necessary data. You can't go back and ask the patient for missing information once you leave the room!
3. Organize your thoughts before starting the note so your writing time is used efficiently. Using the same phrases each time can help. A "telegraph" style is acceptable but the note must be understandable and professional.
4. Be very careful about abbreviations. USMLE has an accepted list but abbreviations risk being misunderstood. Avoid "NAD" - "not actually done".
5. Always be truthful - never record anything you did not do or ask. Besides being unethical, this is clinically dangerous and stupid. (In the SP or USMLE-CS situation it is easily detected by looking at recordings).

Specific Components of the SOAP (PEN) Note

History (Subjective):
Note the instructions ask for pertinent positives and negatives from HPI, PMH, RoS, FH, SH. Faculty strongly suggest you write these headings down the left margin of your note before starting as once you start to write the note, it is easy to miss a specific subheading.

HPI: Start with the age, sex, race using the formula of age, sex, race and chief complaint. e.g. "Patient is a 40 yr old white female complaining of (or presenting because of)" If using a patient quote, mark it appropriately.
Completely, succinctly describe the presenting complaint. Memorize a template for common problems. (First Aid book p. 25-32) Use the mnemonics or whatever helps you to remember a "script" for common symptoms/conditions, especially pain. Address the pertinent positives and negatives for the specific system in the HPI for completeness  (e.g. include shortness of breath, ankle swelling, etc in a presenting complaint of chest pain) Good practice is to end with what the patient thinks or fears as the cause of symptoms.

We suggest a "rule of 4"for each section but individualize to balance getting the data you need in the time available - you must leave plenty of time for PE and discussions with the patient.

PMH: Consider 4 items + 1 in women

1. Serious illness, hospitalization, surgery
2.  Medications (includes prescriptions, OTC and herbs/supplements) give dose and duration of use if known
3. Allergies (frequently forgotten!!!)
4. Status on preventive issues - immunizations, Pap, mammogram, colon screening: give relevant items for patient/case: e.g. colon cancer screening crucial in older patient c/o bleeding per rectum. Pap in young woman.
5. Always document reproductive basics in women e.g. G2P2LC2. Menarche aged 12, regular cycles 3-4/28 no clotting/cramping. Contraception by tubal ligation. In postmenopausal woman, give age and any HRT use

Shorthand example ~
Patient denies past serious illnesses, hospitalizations, surgeries. Tylenol 1-4 /month for headache. Takes no prescription meds, supplements or vitamins. No known allergies. Up to date on immunizations. Cholesterol "low" at health fair 2 yrs ago. No other screening.

SH:

1. Tobacco, alcohol, substances (duration and amount of use) Watch for ex-users. Be sure to ask in patients you don't suspect of "vices". If you get a positive response, go to the detailed  history for alcohol or tobacco or substance (p. 29 of "First Aid" book may be too much but it is comprehensive)
2. Occupation and/or educational history (just key issues, mainly exposures and stressors)
3. Living situation (who lives at home, any stressors, sexually active).  If relevant to case, do full sexual history (see p.29-30 of "First Aid" book but be selective)
4. Health habits especially exercise but can include hobbies

Shorthand example ~
Denies ever used tobacco, illicit drugs. Alcohol 1-4 beers/month. College graduate, schoolteacher, enjoys work. Lives with wife and son (6yrs) daughter (4 yrs). Monogamous, sexually active. No stressors at home/work. Plays basketball on weekends and runs 30 mins twice/week.

FH:

1. Cause of death/significant health problems for parents
2. Significant health problems in siblings
3. Close relatives with heart disease, stroke, diabetes, hypertension, cancer or "anything that runs in the family"
4. Other questions depend on case - e.g. ask more in a breast cancer case about relatives with cancer or ask about sudden deaths in a palpitations case.

Shorthand example (headache case) ~
F67, M64 alive & well. F hypertensive controlled with unknown medication. Sibs (38, 40) no health problems. PGF died aged 54 stroke, no other known heart disease, stroke, HBP, diabetes, cancer in family. No know headache, neurological conditions in family.

RoS:  Brief scan of key symptoms in each system. Textbook list is probably too long. But don't forget mood! Focus on the key items in the differential for each case. What else could explain the symptoms? What other conditions are common in a person of the age/type? RoS is not well addressed in the example notes given in either textbook.

Physical Exam: (Objective)
SP sessions and examinations require focused physical examinations. You must select which systems to examine based on the data required to diagnose and/or manage the case. If you do too much PE, you are taking time away from history and negotiation with the patient. You also give the impression you did not know what to do so automatically did everything. The key issues are:

1. Vital Signs:Usually given in the chart but essential to document in the note. If one is abnormal, check for yourself and comment in the note. In specific cases, additional vitals may be required (e.g. orthostatic BPs and pulses in a fainting case).

2. General Impression of Patient: Lots of individual variation in how this is recorded. Keep this brief but comment on:

1. Appearance (body habits). Mainly weight (obese, overweight, thin, appropriate for height). In some cases, signs of recent weight loss are relevant.
2. Distress/pain. General appearance and apparent severity of pain or distress and relevant issues such as holding a specific body part, restless, or unwilling to move for pain e.g. "appears to be in severe pain, lying still with knees drawn up, unwilling to move abdomen, holding emesis basin."
3. General affect/demeanor. Usually focuses on anxiety or depression. Can include general cooperation or ability to answer questions as in the "alert, pleasant, upbeat, very talkative" elderly lady; also used to document anger, hostility, use of inappropriate language.
4. Other pertinent issues. Specific issues relevant to each case e.g. skin tones - pale, jaundiced, plethoric (rashes and obvious external lesions should have a specific entry in PE): sweating or shivering: smells (e.g. ketotic, alcohol): clothes and grooming may be important as clinical indicators e.g. of self-neglect

3. Pertinent System(s) Exam: Systematically record the pertinent positive and negative findings for the systems(s) examined using subheadings to organize your findings. Both textbooks give the expected components for each body system ("First Aid" book p. 55, "USMLE" book p.23) and many examples of specific cases. In conditions like diabetes and hypertension that cause systemic damage, prioritize the target organs like fundi, heart size, peripheral nerves and circulation.

4. Any Specific Exams: Special items may be appropriate to individual cases.  If necessary, do not hesitate to ask the patient for permission to do a "sensitive" examination (breast, prostate, rectal, pelvic) and document the information you receive. If the patient does not consent but you still think the data from the exam is necessary, document "refused" or "declined" and put "arrange pelvic (or other sensitive) exam" in the diagnostic plan.

The other specific exams are especially common in elderly patients (e.g. ADLs,  IADLs, "get up and go" test) and in children (developmental screening) but include depression screening, MMSE, CAGE questions for alcohol, screens for domestic violence etc. In the exam situation, relevant screening instruments may be provided in the room. Specific items of physical exam include peak flows in asthmatics. Hint: Any unusual piece of equipment or paper in the room usually has a purpose!

Use your judgment about where to best record items such as CAGE, developmental, and domestic violence screening. They may be best in the HPI, RoS or their own heading in the history - but do remember to do and document them when appropriate.

If only performing a focused physical makes you really nervous and you don't want the reviewer to think you just forgot to do something, finish the PE section with a deferred statement e.g. "additional PE deferred" and consider putting items into the follow up plan e.g. "schedule for rectal /prostate examination".

Differential Diagnosis (Assessment)
This section assesses how well you synthesize the data from the H&P into plausible medical explanations AND your sense of the most probable diagnoses for this presentation in the specific type of patient seen (e.g. severe RIQ abdominal pain could be caused by appendicitis in a child, ovarian or tubal conditions in a woman of reproductive age, diverticular disease in an elder, inguinal hernia in a young man).

Follow the instructions noting:

1. You don't have to list 5 if only a few are sufficient.
2. Name specific diseases or conditions and get the terminology/spelling correct - do not repeat symptoms
3. The conditions should be listed in order of probability - you have to commit!
4. The evidence for the conditions listed must be in the note e.g. you cannot list depression if relevant signs, symptoms, history have not been documented.

Note: The focus is always on your patient communication and assessment skills, not your ability to guess "the right diagnosis". Even in USMLE-CS, the scoring system is based on how you conduct the interview and propose a differential and plan. Focus on the most probable explanations for the case and don't try to impress the examiners with "exotics".

In the clerkship, a specific diagnosis may not be clear and the patient may have more than one condition to reflect the realities of primary care and geriatrics. Don't forget to list important comorbidies like hypertension.

Diagnostic Plan. (Note USMLE-CS asks only for diagnostic {work-up} plan. In the clerkship formative sessions, you are required to propose BOTH a diagnostic and a management plan).  You are limited to the five priority items to obtain necessary diagnostic data for the case. Your ability to logically develop a diagnosis and to discriminate between all the possible tests is being assessed. The items listed above for differential diagnosis also apply to testing. Also see advice on page 54 of "First Aid" textbook.

Diagnostic tests could include:

• "sensitive exams"
• laboratory tests (be as specific as possible and avoid "panels")
• imaging studies
• questionnaires and special tests like psychometric or pulmonary function
• specific data gathering such as obtaining BP measures at community sites, keeping pain or symptom  or food intake diary

Consultations and referrals are part of management.

Management Plan (not included in USMLE-CS)
As you will be residents within two years, we want you to practice proposing initial management of cases. All cases in the SP clerkship sessions are based on conditions/situations covered in the course and help faculty assess how well you use the classroom and didactic materials in working with patients. In primary care, a management plan can include:

1. Specific treatments (e.g. Medications - use generic names and be as specific as possible regarding dose, length of therapy, how it should be used etc.)
2. Ancillary treatments such as physical, occupational therapies
3. Patient/family education
4. Community supports
5. Prospective care/preventive services
6. FOLLOW UP  (this is primary care essential!) 

Resources

The USMLE -CS website has information and shows the templates for notes:

http://www.usmle.org/Examinations/step2/cs/content/appendixB.html

http://www.usmle.org/examinations/step2/cs/2009CSinformationmanual.pdf

Both of the popular USMLE textbooks contain good information and sample notes on common cases.

The "First Aid for USMLE" book contains the best overview (page .51-6) and a particularly good template for documenting physical exam items (page 55). Remember to do PE only on those systems pertinent to the case. You do not have time to do a complete physical examination and attend to all the history and communication aspects of the case.

The "Mastering the USMLE" textbook has very little on the notes but a comprehensive guide for review of systems (page 46-7). Probably the best information on notes in this book is in the individual cases.