The SOAP note: a new look at an old friend

With the arrival of the electronic medical record (EMR), teaching students documentation strategies has taken on an entirely new perspective. Once focused on teaching students how to document, the role of NP faculty has shifted to teaching the critical thinking and diagnostic reasoning skills required to summarize a patient encounter regardless of the system used to document care given.  So, is the SOAP note assignment obsolete?

When used as an individual assignment following online problem-based learning (PBL) cases and with some refinement and a somewhat revised approach, the SOAP note retains its timeworn place in teaching NP students how to think like a primary care provider. While the attribute of a symptom delineates the pertinent positives in the note, students often struggle with what pertinent negatives to bring forth from the review of systems.  Although coding & billing requirements often drive this aspect in clinical practice, for teaching purposes the desired outcome is for the student to extract salient data from the PBL case and weave it into a succinct note, allowing the reader to ascertain what working hypotheses the student entertained and whether these were ruled-in or ruled-out based on findings on the history and exam.  Requirements of the refined SOAP note assignment are to include only pertinent information necessary for decision-making, which demands mindful inclusion of data relating to the chief complaint, comorbidities, medications, and pertinent social and family history revealed in the PBL case. This results in a brief, succinct note that recreates the patient encounter in the mind of the seasoned practitioner faculty and provides a glimpse into the diagnostic reasoning process of the student. Guiding the grading of the SOAP note assignment is a “go-to worksheet” that summarizes pertinent information from the case to be included in the note, thereby improving consistency in faculty grading. An analytic rubric guides assigning points with the goal of improving interrater reliability.

This presentation will outline the elements of the refined SOAP note, provide strategies on how to teach the method with examples, explain how to create a supportive “go-to worksheet” and reviews the grading rubric.