To the Editor:
The birth of the problem-oriented medical record (POMR) and SOAP (Subjective, Objective, Assessment, and Plan) note marked an epoch in the history of health care. Dr. Lawrence Weed, developer of the SOAP note and professor of medicine and pharmacology at Yale University, challenged conventional medical documentation and advocated for a scientific structure to frame clinical reasoning in the 1950s.1 With the passing of Dr. Weed on June 3, 2017, it is time to revisit the SOAP note’s original intent.
The inspiration of the SOAP note transpired after Dr. Weed found a lack of documentation within the art and science that make up the essence of medicine. His primary ambition, to create notes where physicians could distinguish relationships between various problems, has been degraded, which has in turn affected clinical decision making. Nowadays it is not only physicians who interact with the note but also patients, billing and legal professionals, administrators, researchers, and other health practitioners. Each entity interacts with the same note in a different way, stretching the utility of a SOAP note to a point of ineffectiveness.
While patients’ involvement in their own care is encouraged, the format of today’s medical notes dissuades their participation. It is the patient’s personal information that is lost among cluttered, autopopulated data, leading to a note that is overloaded with information and that is often difficult to read. Documentation that follows reimbursement criteria takes precedence over additional time spent with patients, leaving the patient, as Verghese2 notes, “still at the center, but more as an icon for another entity clothed in binary garments: the iPatient.”
Ineffective communication contributes to the top causes of sentinel events and continues to be an unremitting area for refinement, even though the POMR was intended to improve communication.3 A platform where a physician could organize his or her thought process, assessments, and care plan would, in theory, allow other providers to utilize that information in patient care and improve patient autonomy. Unfortunately, the SOAP note no longer fulfills this role. So, once again, it is time to stand with Dr. Weed in advocating for a new clinic note format to bring back a more accurate representation of what medicine is all about.
Fourth-year student, Texas Tech University Health Sciences Center, School of Medicine, Lubbock, Texas; [email protected]; ORCID: https://orcid.org/0000-0003-2737-4128.
J. Drew Payne, DO
Assistant professor, Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas; ORCID: https://orcid.org/0000-0002-9708-2641.
1. Wright A, Sittig DF, McGowan J, Ash JS, Weed LL. Bringing science to medicine: An interview with Larry Weed, inventor of the problem-oriented medical record. J Am Med Inform Assoc. 2014;21:964968.
2. Verghese A. Culture shock—Patient as icon, icon as patient. N Engl J Med. 2008;359:27482751.
3. Joint Commission. Sentinel event statistics released for 2014. https://www.jointcommission.org/assets/1/23/jconline_April_29_15.pdf
. Published 2015. Accessed September 26, 2018.