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The doctors in our practice will like to be able to write a simple SOAP note. Anyone can tell me how to achieve this?

http://en.wikipedia.org/wiki/SOAP_note


If one would like to leave out PMH, ROS, FH, etc..... just eliminate them. You can fill in whatever you want in the spaces as appropriate.

Honestly, doesn't really cut it anymore as doesn't fulfill insurance guidelines, but it can be done.

Ican,
It's interesting to me that you should ask this question, especially as your first post; it was my first post about three years ago.
I got a bunch of answers from posters who are still often here (Bert's response was a brief "You can't.") and from some who are not (Travis probably gave the most helpful, to the point response).
I was taught about SOAP notes in medical school, and have tried to use them almost exclusively since then for follow-up visits. I find it interesting that so few people (at least those on the board here) find that format to be useful.

In retrospect, this question provides some interesting insight into AC and how it works. While some surveys show that AC ranks very highly in terms of "flexibility" and "adaptability"...at least as compared to other EMR's...it has its limitations. So Bert's answer is correct, in one sense. You cannot change the headings in notes (CC, HPI, PMH, etc.) nor can you change their order.

On the other hand, if you want to send SOAP notes to others, you can do so. The "print notes and letters" box (which can be defaulted to show up as you sign off every note) allows you to print each note in SOAP format, if you choose to. When the box comes up, under "2. Select header for note", there is a drop-down menu, and the choices include a SOAP note.

Another aspect of AC that this reveals is that you can often access or do things in several different ways with the program, sometimes with varying results. For example, you can view or print notes in different ways at different times with various appearances of the note.

I hope I didn't confuse you with that. Welcome to AC and the board.

Believe me. Attending the University of Vermont College of Medicine where Larry Weed, M.D. was its distinguished professor and inventor of SOAP and POMR, I had the SOAP note drilled into me.

I guess I don't understand why including PMH and PSH, etc. is so different from a SOAP note. I guess you could make the argument that you have come to be aware that the patient had an appendectomy, but I don't think that forces you to think of it as objective data. So, I don't think others are against the SOAP note, nor do I see how to save a SOAP note in the visit history.

I too do not see the problem. The AC format is basically SOAP, just not with those headers. It is just a little different means to the same end.

Well I can live with it, too.
The main issue (especially for a specialist) is being able to create a readable note that is informative but does not contain excessive verbiage (as do those produced by so many EMRs). This unfortunately runs counter to the current payment guidelines that we must follow to get paid; as you know, according to those, a full SH, FH, and ROS on EVERY note is paid more.
In a sense, what AC does is pretty smart; we produce a note that has all the extra "stuff" (and that is saved) but it allows you to print a SOAP note to send to referring providers.

Personally, I am more impressed by someone who sends me a complete note, letting me know that they have indeed recorded that the patient is diabetic or has a family history of colon polyps or is taking lithium rather than just an abbreviated SOAP note. I do not, however, need a formally dictated consultation.

I agree with Leslie - I am frustrated when a specialist sends me consult note and I see that they are prescribing the same meds that we have already tried and/or note that they never reviewed what meds pt is already on. I would rather see that they did full exam.

In Jon's defense, it would be great to have the best of both worlds. If you don't use PFTs or an O2 sat in your note, it shouldn't show up on the note. That does look terrible.

We all judge EMRs by how we did it with paper. And, we certainly would write HR 80, Temp 98.6 RR..... O2 Sat..... PFTs, etc.

This is why it is SO much harder to be a specialist...each one of you wants something different. (Quick, how do I turn on the sarcasm font before my entire practice goes down the tubes?)

It's simple...tongue-in-cheek: We just want you to see them the next day, diagnose their problem, agree with everything we told them and make it sound like we made the diagnosis, call us five minutes after, have the note to us next day (in color), and schedule, read, interpret all labs and procedures.

JUST KIDDING, sort of...

Actually, this would be a great jumping off point for specialists to post things that drive them crazy about primary care and we can do the same about specialists. Probably would be good for everyone.

I know I have my favorite...(that would be well answered by specialists on here).

NA is a very useful abbreviation and I for one would not think poorly if a specialist used that next to the PFT. At least it leads me to believe the specialist knows what PFTs are Even as a primary care,I may not always be the doc doing the Pap or the rectal or the prostate exam. Here is where I use shorkeys such as NEGYN (not examined, performed by the gynecologist). I have acknowledged that I know what a Pap is and that certain people should have them done and who the patient or I have declared should be responsible for doing it. As a specialist, a simple DPCP (deferred to the primary care physician) would be fine. If an orthopedist sends me a note that says "The neck was without thyromegaly or lymphadenpathy" then I am going to have a lot of trouble taking any part of their note seriously.

Queen of the shortkeys. Love Leslie. But, for my note, I don't want to put N/A by PFTs.

But see, Leslie makes a good point on the thyromegaly and lymphadenopathy. I think this could go somewhere.

On one note though, if they used abbreviations, they would need to put the key at the bottom. I wouldn't know what DPCP was.

No, Bert, that is the beauty of shortkeys. I simply type in DPCP but the macro that actually come out may say something like "this exam was performed by the patient's Primary Care Physician". I hate abbreviations in notes. NA may actually come out "this was not considered a relevant part of this exam". I am lost without shortkeys.

OK, since it didn't take off as planned, I will ask my question of the specialist of which Jon seems the most logical. This is not too much of a complaint, more as how does the specialist prefer this to happen and how much does the specialist consider the PCP to be a pain in the [censored].

So, this issue has come up twice. Once a week into practice and once three weeks ago. That is a span of 17 years. Both times the specialist became very upset with me on the phone and, given how loud he was and the fact that I didn't say anything for over a minute, my staff knew and it was embarrassing. So, this is about the telephone consult. Now, as stated, nearly 99% of these are successful, but I do know that some specialists aren't extremely fond of it. Plus, depending on the doctor and the specialty, they are done differently.

Many times I will have a patient in the room and a recommendation from the specialist will be extremely helpful. Of course, that means the specialist (can we make S mean specialist?) has to stop what she is doing just to accommodate you. But, just to state it, that is the ultimate help. Now the problem that came up and may be there but not vocalized is the S doesn't like being liable for giving advice about a patient she hasn't seen. It is this premise I strongly disagree with. In my view, it is partly how you say it that makes a difference. I think if the S says to you, "For your patient, I would obtain a urine micro via cath and a CBC and if they come back between these values, I would observe." Or she could say, "When I have a patient like that, I tend to obtain a cathed urine...." I know they are the same, but the latter seems to impose less liability.

Another thing I have observed is the following: When I call a S, many times it may take hours to days to get a reply. It feels as if the S thinks her time is more important than mine. That I need her more that she needs me. AND THE KEY THING IS...I can understand that. I think it is untrue, but I don't see how a specialist can't think that I need them more than the other way around, therefore, they may not be as quick to get back to me. I have often said to my staff a consultant more call me in four hours or 24 hours (almost always using a secretary to buffer the call), but they must know, that when they call me, they will have me on the phone within 30 seconds. I suppose part of this is the immediacy of the event. A phone consultation may happen within hours whereas a consult could be weeks away. Even so, the S would not have patients if the PCPs didn't refer to them.

I just feel it is extremely important for the PCPs and the specialists to work together. Many times I am just calling to see if the patient needs to be seen sooner than later by her. In defense, the S who went off on me on the phone is a pulmonologist, probably the S who would be giving me advice on the sickest patient. It's not like a dermatologist needs to be too worried when they advice you to use Triamcinolone 0.1%. He did tell me I consulted him more than any other pediatrician. I emailed him back a lesson in statistics. There has to be two ends of the curve. The doctor who has never called him. And, the one who has called him the most. That doesn't make me a bad doctor. And, he told me to use the local pulmonologist. I told him I preferred using him.

As stated, I hope this didn't come across as complaining. I would just like to hear what other PCP's experiences are and what the specialists think. Do they mind the phone consultation. Do they get extremely annoyed when the PCP asks if she can get out of a room. It is nice when the MA can ask if you want to wait or get her out of the room. 90% of the time, I tell them I can wait. Of course, sometimes it is seven days, and I can't even remember why I called, a good reason to write it down.

Bert,

As I get older and wiser-ha!, it seems I call the specialists less, and this may also be due to the technology at my fingertips (up to date, medscape epocrates). However, generally am able to get the specialist on the phone within minutes, unless they are in a procedure, and usually call back within the day.
Also with the immediacy of dragon creating notes/updox and efaxing, phone calling is becoming less important for the transmittal of info.
But, like you if a physician calls, my nurse pulls me out of the room, I try to respect my colleagues time, and my patients never complain when I excuse myself (at least to my face).

Like, Jimmie, I rarely call consultants but, when I do, I have not had any trouble getting them to talk to me right then. Maybe it is because they have learned over the years "When Strouse calls, it is important." Most of the time when I call it directly concerns how I should treat a patient until they can see them, do they want the guy in my office with a complete heart block directly admitted to them or sent to the ER? Sometimes, though, I will call if my staff is having trouble with a specialist's office. The biggie here is when they try to make an appointment with, say a rheumatologist, and are told they have to fax my notes and all the labs over to them first so he can look at it before he decides if it is an appropriate referral and he will see the patient. I will then personally speak with the rheumatologist and tell him he has insulted my intelligence and that, in all likelihood, I will not be sending any more patients to him.

Bert, why do you continue to send your patients to a specialist who sounds like a jerk, berates you, doesn't work locally, and sounds like he doesn't even want your patients?

I guess as an ophthalmologist I count as a specialist, so I'll answer your questions. First of all, what are you calling these specialists for? Are you just calling them to ask for advice? As in, "what antibiotic should I give to my patient who I think has conjunctivitis (the answer: nothing, most conjunctivitis is viral. If you think it?s bacterial, they need to see an ophthalmologist. Also, for the love of God, please don?t ever prescribe Tobramycin or Gentamicin!!! That stuff is toxic to the eye and should only be used by an ophthalmologist under certain special circumstances!!!)?? Or "what steps should I take to work-up a patient that I think might have pyelonephritis/a UTI (I thought maybe that's the question you were asking when you used your example about obtaining a micro cath and a CBC)?? Or "what medicine should I prescribe for this rash my patient has?" If you were repeatedly calling me with questions like this, I would be inclined not to answer you back in a timely fashion. I would have to say, if you have to call a specialist to ask how to treat a patient, you shouldn?t be treating that patient, and you should just send them to the specialist. Or like jimmie says, look it up on the internet. If you tend to call me with questions like, ?for this patient that I think has temporal arteritis, should I send him to your office or send him to the ER??, I would be more inclined to return your calls more promptly. Or if you tend to call to tell me why you?re sending a complicated patient to me, I would be more likely to continue to return your calls promptly. Unless I?m in the OR; then you?ll have to wait. That?s one of the reasons why specialists take longer to return calls than PCPs. A lot of the time, they aren?t in the office because they?re doing surgery or procedures. Actually, as someone who sees way too many patients who were initially diagnosed with ?conjunctivitis? by their PCPs, when in reality they really had uveitis or scleritis or a corneal abrasion, etc. etc., I would prefer it if more PCPs would call me instead of improperly treating their patients. Or just send your patient over to see me. I, unlike your friendly pulmonologist, will not be mad if you send me too many patients. And when PCPs refer a patient to me, I prefer to send a quick dictated letter, mostly because if I sent you guys my ophthalmology note, you probably wouldn?t understand half of it given that it mostly consists of ophthalmologic nonsense. By the way, I did call a cardiologist once (because he asked me to call him about his patient), and I was on hold for fifteen minutes before I got pissed off and hung up. I?ll never call him about his patients again.

Does that help answer your questions, Bert?

Hi ALR,

Thanks for your response. Actually, it isn't "a" question, it was an attempt at starting a dialogue between PCPs and specialists. I don't think it really worked. I will try to respond to some of your comments.

Many times I am asking for advice. I don't usually ask about antibiotics. Just use Vigamox. UTI is a good example, but it should be on record that I have worked up and admitted more than I care to remember. Rash questions are good. Some can be extremely tough and a good dermatologist can fix it in minutes. Yes, these may be the questions, and yes from my perspective I would expect a quick answer. And, in turn, I would refer my patients. I completely disagree with the notion that if I have to call a specialist to ask how to treat a patient, you shouldn't be treating that patient. I certainly can't agree with that. If I have a 16 year old with heavy bleeding, I can't do the workup but ask what dose of estrogen would be good to use? I don't think I need to refer that patient, but they usually let me know it is OK. If specialists could see patients in a week, great, but this patient may be waiting a month.

I do believe I spend a fair amount of time on the Internet. Many times using it 15 minutes or more in the room. So, from what I am hearing, it depends on the type of questions (good or bad) as to how long it takes to get answered.

It isn't about how quickly they are returned. Most specialists here have MAs that say, "I will give her the message, and she should call you when she gets back," That's great that you will see the patient right away. Not all consultants do that.

I guess what I would have an objection to is why is it up to the specialist to decide when he/she calls back. That goes back to the specialist sort of coming across like they are more important.

I think most of my calls are legit, and I do try to work with specialists to help my patients. I am usually calling about mitochondrial disorders and Diamond-Blackfan Anemia, and AML, Dermatomyositis, Hyperaldosteronism, etc. Of course, there are lots more mundane questions.

Bert, I don't know why it is up to the specialist to decide when he/she calls back. Perhaps a lot of the specialists are just jerks that think they are better than you and that their time is more valuable than yours. That's the only reason I can think of.

Well, actually, in the current re-imbursement scheme, their time is more valuable than ours

I am on both sides of this Specialist vs PCP issues. I am a PCP by board certification. I am Family Practice. I am also Sports Medicine and I really am only a specialist in this area...there are a couple random exceptions where people who don't have docs and see me for sports injuries or ortho stuff, come to me for random blood tests and such.

So from the point of view of the specialist, I would like to see a note from the PCP on what they did for the patient already and their thoughts. It is funny. I am the specialist now and I always hated when specialists didn't send me notes or communicate when i was in FP residency but now it is the opposite, i don't get a response from the PCP. I don't get notes, i just get a patient showing up saying so and so sent me here.

From my point of view on notes, I only send the first note (initial visit) and the discharge note on each patient's problem. So if they showed up a month later with an arm injury and i already saw them for a leg thing but the PCP didn't send them, I still send a note so the PCP knows that there was an arm injury now and I am treating them for it and then when I am done.

thoughts?

and leslie..the specialists increased value is going to be taken away once everyone jumps on medicare ship of not allowing us to charge consults...right now BCBS of michigan already doesn't allow us to charge consults.