Just reflecting on what a SOAP note has traditionally been (in my non-MD understanding), the original idea was to use the 4/5 headings to capture things to do with a specific problem in a clean way during consultations and further ‘clinical thinking’. We don’t need to discuss this now; SOAP is a very good model, epistemologically speaking (the common 7+ headings used in many hospitals has another explanation - let’s avid for now), so let’s just assume that SOAP headings are a good idea.
In early attempts at the EHR, my impression is that a new SOAP note was created in each consultation, and that previous SOAP notes were treated like any other forgettable item in the EHR, like a BP measurement from 3 month ago. But is is pretty clear that SOAP notes (if they are to be used) should really be considered as ‘persistent’ Compositions (in openEHR, a ‘persistent’ Composition is one containing content that is at least potentially valid for all/much of the patient’s life, e.g. most managed lists, family history, vacc history and so on). If we treated SOAP notes as persistent things that were always retruned to with each new consultation, lab result, and intervention on that problem, the POMR view of things would be very clear.
The potential problem, at a computing/data level, is to implement the idea wrongly, and to actually include inline the data items being generated by all these activities, inside the SOAP note. This won’t really work for at least 3 reasons:
- many Obs (including VS & labs) relate to multiple problems, e.g. most vital signs - do you record copies in all (say) 4 extant SOAP notes? No - that kind of data cloning destroys querying.
- quite often, docs and nurses do Obs that don’t relate to a specific problem. In the ER, the problem might not be known for some time; a GP health checkup is not a problem-specific consult… so in these cases, you don’t have any SOAP note to which you would attach the data.
- it is often only clear later on which problems any given Obs, Dx etc relate to, so really, the freedom is needed to commit isolated info (e.g. recorded by patient devices) to the EHR, and then (maybe) link it to SOAP notes later on.
In openEHR, most if not all implementations I know of already operate on a ‘commit-data-now’ basis, without trying to be very POMR. To make an openEHR EHR a POMR, I would say that any SOAP note has to be given a status of ‘persistent’ (or maybe some new status, like ‘ongoing’, which could be changed later), and then, as different treating docs work with patients, they will progressively compile the content of any SOAP note, using linking to committed EHR content. This means a) post-hoc SOAP note building can occur; b) more than one SOAP note can refer to the same Obs, labs, Dx etc; c) querying for clinical Obs, Dxs etc remains independent of SOAP notes and d) SOAP notes don’t get lost in the miasma of past event data, they are instead headline parts of the EHR.
In this way, SOAP notes, inasfar as they are used in any given EHR, become a progressively built view of each problem, not just a way of structuring an encounter note.
What do the healthcare professionals here think about this view?