Updated on: June 11, 2019

Thinking Outside the S.O.A.P. Bubble

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Original story posted on: June 10, 2019

Maybe it is time for physicians to stop being S.O.A.P. bubbleheads.

There is no denying that poor documentation is a serious, universal problem. However, most of our documenting colleagues are in serious denial about the problem. But some of the denials flying about in the locust cloud of insurance denials have an unexpected silver lining, albeit a small one. These are the insurance denials that are themselves undeniable, i.e., the valid insurance denials based on poor documentation of medical necessity or its absence of medical necessity altogether. Some insurance denials defy clinical sense, but some insurance denials reveal a deficit of clinical sense.

Most of us physicians, however, document poorly because we see it as a bother. Most of us physicians work in a seemingly vast sea of competing bothers. Most of us physicians only bother to deal with the things that bother our patients and ourselves the most. Documentation has always been a poorly competitive bother to physicians who see it as an unaffordable luxury in our time impoverished practices.

It is the nature of documentation to be bothersome. We already know what we are going to document because we have just mentally and physically done it with our daily patient evaluation and treatment. We dislike documentation because it is redundant.  So we document in a heedless way because we see it as needless. We see it as a bother.

The history of documentation in medicine is the history of doing as little as fast as possible. With speed came vagueness, initially short and scribed documentation became merely clinically nebulous.  With the evolution into electronic records, the notes became ponderously amorphous – many words without meaning. The electronic medical record (EMR) allowed doctors to minimize the bother. We could just copy/paste what we bothered to concoct yesterday or something someone else had concocted.

The history of documentation in medicine is also the history of clinical documentation improvement (CDI). It was their business to bother doctors into bothering to improve a responsibility physicians considered bothersome.

Well, in my 45 years in medicine the CDI industrial complex has been hard at work to improve documentation but despite the efforts of my stalwart, talented colleagues and their dedicated, expert programs, lousy documentation always manages to remain out reach of correction like the first down marker in NFL football games.

What to do?

Perhaps, it is time to think outside the S.O.A.P. (Subjective, Objective, Assessment and Plan) bubble. The SOAP bubble was blown up by the rightly revered Dr. Lawrence Weed in articles about the ‘problem-oriented medical record’ written in the mid-1960s when clinical notes were malnourished. But the EMR is the obesity epidemic of documentation. The envisioned sleek hand-written SOAP notes are now the blubbery electronic SOAP notes.

So what is outside the SOAP bubble?  Perhaps just a smaller bubble with room for three things:

    1. Why the patient needs to be in the hospital
    2. What is being done to treat this
    3. Why the patient cannot go home

So what does a locust cloud of denials have to do with the SOAP bubbles? Perhaps, we can only improve our documentation by changing it – by popping the bubble.

Finally, if you are feeling a whiff of blasphemy or sacrilege, consider this: has the EMR made the SOAP note obsolete? When we can navigate to every lab, ECHO, EKG, CXR, MRI, CT, C&S in an instant, why clutter our notes with this stuff?

When I read electronic SOAP notes they make my eyes sting.


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Michael A. Salvatore, MD, FACP

Dr. Michael Salvatore was a pulmonary medicine/critical care physician for 35 years. Since 2012 he has been the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. After earning his MD at the University of Arizona, he trained in internal medicine and PULM/CCM at Duke University. Dr. Salvatore is a member of the RACmonitor editorial board.

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