Ch 02: THE FORMAT: The SOAP and its place in Medical Documentation (check image)
Time to change gears. If we are satisfied with the ‘why’ of medical documentation and the logic that surrounds it, it is time to move on to the ‘how’ of medical documentation. We can now begin to learn how we can create accurate, thorough and meaningful entries into our patient’s medical record. For our purposes we will be documenting using the SOAP note format you are somewhat familiar with. However, let’s take a moment to frame how the SOAP note fits in today’s documentation strategies. To do that, we need to first explain something referred to as EMR or The Electronic Medical Record.
In years past, healthcare workers: doctors, therapists, nurses, would all ‘handwrite’ their notes into the patient’s medical chart (Yes, the chart was actually a physical, hold-in-your-hands chart full of paper that we would write on.). Be it in a hospital, nursing home or outpatient PT clinic, medical documentation was all handwritten. Several years back however, that changed. Today we now live in a world where all of the patient’s records/notes/documents are keep electronically — on computer. This computer-based / electronic format is called EMR. One of the results of this change from paper to computer was the emergence of a wide array of medical documentation software systems and packages. Yet, despite the number of different systems out there, they are all essentially build around logic, principles and format of the SOAP note.
When you are completing your affiliations, you may very well find that each of your clinical sites has a different EMR system. When you chat with your classmates, you may find that they were at clinics that had systems different from any of yours. That is one of the reasons why many PTA programs do not teach a particular EMR system, but rather focus on the ‘logic’ of medical documentation. Given just how many EMR systems and software packages are out there, it would be impractical to purchase each of them and then attempt to teach you how to use them all. This is especially true given, as we have said, that no matter the platform or software, the documentation system will be based on the logic/format/principles of a SOAP note.
For this reason, if we develop a clear understanding of the SOAP note and how to use it effectively, we can use its principles to document in any system. Further, if we understand the ‘logic and rules’ of medical documentation (which we will be discussing at length in this booklet), then we will not only be able to be great written communicators, we will also be able to read and interpret all sorts of medical documentation – no matter its form.