Medical Documentation

Objectives

• List the components of a SOAP note
• Explain the elements within each component of a SOAP note
• Identify where specific patient information should be placed within a SOAP note
• Apply SOAP note principle to document a patient encounter

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SOAP Notes & Progress Notes

• Purposes of documentation
• Improving patient care & outcomes
• Providing patients with information about their care
• Enhancing continuity of care
• Ensuring compliance with laws & regulations
• Protecting against professional liability
• Creating a record of services provided for billing & reimbursement
• Establishing the pharmacist’s credibility as a healthcare provider
• Subjective
• Information provided by the patient, family, or caregiver
• Thorough, but concise
• Descriptive and cannot be measured directly
• Chief complaint (CC) - in patient’s own words
• Usually provided in quotes
• May not always provide a specific complaint
• History of present illness (HPI)
• Initials, age, race, gender
• Further description of patient’s complaint
• SCHOLAR
• May not have complaints
• Past medical history (PMH)
• Complete listing of childhood & adult illnesses
• Includes diagnosis
• Ideally include duration/year of diagnosis
• May include surgical history
• Family history (FH)
• Include FH of first-degree relatives only
• Mother, father, siblings, and children
• If FH does not impact therapy decision, can write as non-contributory
• If unknown, can document as such
• Social history (SH)
• Health/lifestyle
• Exercise
• Diet
• Alcohol intake
• Tobacco
• Illicit drugs
• Living situation
• Occupation
• Insurance
• Positive/negative use
• Quantify how much
• Medications
• All prescriptions, OTC, herbals/supps
• Include:
• Name
• Strength
• Route
• Frequency
• Duration
• Allergies
• What is the allergy & reaction?
• When did this occur?
• If none, write NKDA
• Immunizations
• Include immunizations that the patient has received and the year it was given
• Review of systems
• Set of questions asked that pertain to symptoms associated with each body system
• Will indicate the body system, symptom asked, and which are positive vs. those that the patient denies
• If not performed, can document as “deferred” or “not performed”
• Objective
• Data obtained by the clinician, EMR, Lab work, and diagnostic tests
• Can be measured
• Should only include the pertinent positive and negative findings
• Vital signs
• BP, HR, RR, temp, height, weight, BMI
• Physical exam
• Includes pertinent observations & results of any physical exams
• Broken down by organ system
• Head, ears, eyes, nose, throat (HEENT)
• Neck
• Chest
• Heart
• Abdomen
• Musculoskeletal
• Extremities
• Skin
• CNS
• If not performed, can document as “deferred” or “not performed”
• Laboratory tests
• Includes pertinent lab values for the patient such as Basic Metabolic Panel (BMP) or Complete Blood Count (CBC)
• May also include additional labs such as:
• Lipid panel
• Blood glucose
• Hemoglobin A1C
• Pregnancy test
• Often compared to previous values to show trends of increasing or decreasing values
• If all normal values, may document as WNL (within normal limits)
• Serum drug concentrations
• Include results for drugs that require blood drug monitoring such as vancomycin, phenytoin, valproic acid
• Include target or goal levels
• Diagnostic tests
• Broad spectrum of diagnostic tests such as EKG, X-rays, blood cultures
• May be the actual image or an interpretation of what was seen
• Problem List
• Prioritized by importance
• Problems are numbered
• Problems can be defined by:
• Patient concern/complaint
• Provider concern
• Disease that has not been diagnosed or treated
• Abnormal lab test/exam finding
• Social or financial situation
• Drug therapy problem
• Includes all medical problems, even if controlled
• Usually falls between objective and assessment sections
• Assessment
• Outlines what the practitioner thinks the patient’s problem is based on subjective and objective information
• Includes active problems (including problems which are controlled)
• Helps other healthcare providers reading the note to understand how the clinician arrived at their assessment
• Disease assessment (supporting evidence)
• Often includes severity or current status of a disease state
• Includes evidence to support practitioner’s thinking
• May also include potential causes
• Goals
• Clear, achievable, and measurable
• May be short- or long-term goals
• Refer to treatment guidelines from national organizations
• Can include functioning, survival, or event prevention
• Plan
• Includes actions needed to resolve the identified problems
• Pharmacologic
• Provide a complete description of the drug recommendation
• Drug
• Dose (calculate if weight-based)
• Route of admin
• Frequency
• Duration of therapy (not always known)
• Do not always need to change medication
• Non-pharmacologic
• Lifestyle modification
• Involve patient in development
• Do not always need to change here, but can encourage current routine
• Avoid duplication of content among the plan sections
• Education & counseling
• Briefly mention most important counseling points that should be communicated to the patient for each problem & treatment
• Remember DI resources
• Include details of non-pharm recommendations above
• Include counseling for side effects of medications
• Monitoring & Follow-Up
• Include what is to be measured, how often, and where the patient should go to have this measured
• Include monitoring for efficacy and safety
• Efficacy = is the treatment plan working?
• Safety = is the patient experiencing any side effects?
• Rationale
• Discuss your thought process for the treatment choice
• Recommendations should be evidence-based
• Reference disease state guidelines
• State why or how guideline recommendation applies to the patient
• State why or how the medication will help treat the condition (ex. Mechanism of action)

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Helpful Tips

• DO
• Be specific & make a complete recommendation
• Take ownership of the patient’s care (plan should not be “referral to physician” for every problem)
• Be brief & concise
• Use descriptive terms including med terminology
• Document immediately after (or during) each session
• Start each note with date & time
• End each note with a signature including your title
• Abbreviate as much as possible
• DON’T
• Avoid duplicating information
• Avoid vague recommendations
• Avoid listing multiple treatment options – pick one!
• Avoid unapproved abbreviations
• Avoid using judgmental words to describe a patient (ex. stubborn, lazy) or a medication (inappropriate, wrong, senseless)

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Practice Notes

• Subjective
• CC: “I am here to have my blood pressure checked again and see if I need any new medicine”
• HPI: follow-up after receiving a screening at ONU Healthwise mobile clinic on 8/19/22. Pt said BP was “a little high” that day. Referred here for BP management
• PMH: high blood pressure
• FH: mother - (deceased) heart attack at 50 yo, healthy father, healthy siblings
• SH: eating out 1-2 times per week, cup of coffee & can of soda q day; walk 2-3 times q week; no cigs or nic; no drugs; 1-2 beers q weekend; no cost issues, no insurance issues
• Meds: Lisinopril 10 mg po qhs; Tylenol for headaches 1-2 times q month; no herbals
• Allergies: NKDA
• Immunizations: Pfizer covid Vaccine 6/22, flu shot 10/21
• ROS: deferred
• Objective
• Vital signs:                 BP: 116/70        (Goal = < 130/80)
• HR: 78                        (Normal: 60-100)
• RR: 16                 (Normal: 16-20)
• Temp: 98.6
• Ht: 5’11’”
• Wt (kg): 100 kg
• BMI: 30.7
• Physical exam: deferred
• Labs: WNL
• Problem List
• Hypertension (#1)
• Occasional headaches
• Assessment
• Disease assessment: controlled HTN (116/70)
• Goals: Maintain BP < 130/80; reduce overall lifetime risk of heart attack and stroke
• Plan
• Pharmacologic
• Continue Lisinopril 10 mg qhs
• Non-pharmacologic
• Continue exercise 2-3 times weekly & keep eating out to 1-2 times per week; cut back on caffeine to 1 cup of coffee or 1 soda per day
• Education & counseling
• Lisinopril may cause cough
• Monitoring & follow-up
• Follow up with pharmacist in 3 months to re-check patient’s BP

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Physical Assessment & Abbreviations in Progress Notes

• O of SOAP notes
• Physical exam
• Includes pertinent observations & results of physical exams
• Typically start at the top and move down:
• HEENT (head, ears, eyes, nose, throat)
• Neck
• Lungs
• Heart
• Abdomen
• Genitourinary
• Rectal
• Musculoskeletal & extremities
• Skin
• Neurologic
• If not performed, may document as “deferred” or “not performed”
• Inspection: general observation of patient
• Palpation: use of the sense of touch in the evaluation of the patient
• Percussion: used to produce sounds, elicit tenderness, or assess reflexes in a patient
• Auscultation: involves listening for normal and abnormal sounds with a stethoscope
• Diagnostic tests
• Broad array of tests
• May be the actual image of an organ or an interpretation of what was seen
• Imaging tests (ex. x-ray, MRI)
• Electrophysiology (ex. EKG, EEG)
• Screening results (ex. blood cultures)
• Risk calculations (ex. 10 yr ASCVD risk)

HEENT

• Physical exams may include:
• Head: Hair, scalp, skull, face, skin
• Eyes: general inspection, reactivity of pupils, ophthalmoscopy, extraocular muscles
• Ears: internal inspection, otoscopy
• Nose: external inspection/palpation, otoscope
• Throat/neck: inspection of mouth & pharynx, palpation of lymph nodes & glands
• Abbreviations
• NCAT = Normocephalic atraumatic
• PERRLA = pupils equal, round, and reactive to light and accommodation
• EOMI = extraocular muscles intact
• Imaging
• Can visualize a stroke, tumors, blood flow, etc.
• EEG (electroencephalogram)
• Measures the electrical activity of the brain

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CHEST, HEART, LUNGS

• Physical exam: inspection, palpation, and auscultation
• Dyspnea (labored breathing)
• Breath sounds
• Cough & sputum
• Chest pain
• Palpitations
• Abbreviations
• RRR = regular rate & rhythm
• Chest radiograph (CXR): very common when evaluating lung conditions
• Consolidation: areas of the lung where air should be, but it is not
• Replaced with fluid, pus, and/or blood
• Infiltrate: dead cell, debris, pus commonly seen with pneumonia
• Atelectasis: partially or fully collapsed lung
• Pleural effusion: fluid in the space between the chest wall and lungs
• Aspiration: inhalation of food particles or stomach contents
• Computed tomography (CT) scan
• May be done as a follow-up scan to a CXR
• Provides better detail than a standard x-ray
• Can assess for pulmonary embolism, lung masses, internal bleeding, or edema
• May require administration of IV contrasts
• “Echo”: echocardiogram
• Ultrasound of the heart
• Provides information about the size, shape, and pumping ability of the heart, as well as visualization of the heart valves
• EKG or ECG: electrocardiogram
• Measures electrical activity of the heart
• Can show heart rate & rhythm
• Can show parts of the heart that are too large or overworked
• Cardiac catheterization
• “Going to the cath lab”
• Procedure to look for disease in the heart muscle, valves, or coronary arteries
• Coronary angiography: contrast dye is injected through a catheter. X-ray images show the dye as it flows through the heart arteries. This shows if the arteries are open or blocked
• Angioplasty or percutaneous coronary intervention (PCI): when a catheter is used to clear a narrowed or blocked artery or a cardiac stent is placed
• Pulmonary function test (PFT)
• Spirometry
• Measure of lung volumes, useful in asthma and COPD
• FEV1: forced expiratory volume in 1 second
• FVC: forced vital capacity

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ABDOMEN/GI

• Physical exam: assess the four quadrants of the abdomen
• Inspection: color, texture, vascularity, contour
• Auscultation: bowel sounds, vascular sounds
• Percussion: fluid, gaseous distention, and masses
• Palpation: areas of tenderness, muscle spasms, or the presence of fluid or masses
• Esophagogastroduodenoscopy (EGD)
• Endoscopic procedure that examines the esophagus, stomach, and duodenum (part of small intestine)
• May help locate a GI bleed
• Biopsy may also be done at the same time

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LOWER EXTREM.

• Physical exam
• Leg pain, skin abnormalities, edema, hair growth, nails
• Palpate pulses in extremities
• Evaluate joint rotation and reflexes
• Doppler ultrasound
• Quick way to check for problems with blood flow
• DVT: deep vein thrombosis

Microbiology

• There can be many sources of infection in a patient
• Urine → UTI
• Lungs → pneumonia
• Skin → cellulitis
• We often start antibiotics to help with the infection before we know what bacteria is growing → empiric coverage
• A sample is collected from the source of the infection and sent to the microbiology lab
• They culture it to see what bacteria grows and what antibiotics are most effective in killing it/inhibiting its growth
• Antimicrobial stewardship = improve how antibiotics are prescribed by clinicians and used by patients
• Based on microbiology reports
• S = sensitive
• bacteria will be killed by antibiotic
• R = resistant
• bacteria will not be killed by antibiotic

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