Larry Weed and SOAP notes

1973, as we prepare to start our clinical rotations, the chief medical residents taught us the new concept of SOAP notes.  Larry Weed developed the concepts of the problem oriented medical record and notes that included subjective, objective, assessment and plans for each problem.  We wrote our notes each day using his system. I have wondered in many conversations what he would think of the unreadable computer printout notes of 2017.  We wrote notes on each problem with a careful assessment and plan.  We had no concern for doing a complete review of systems and physical exam each day, rather we focused on the patient’s problems, including subjective complaints, abnormal physical findings, abnormal laboratory tests and images.  Each day we reviewed our problem list, sometimes resolving a problem, sometimes adding new problems. I remember several patients during my internship that I am certain benefited from my careful listing of problems and thoughtful assessments and plans.  Our subjective (history taking) and objective (physical exam, labs tests, etc) remarks were attached to a problem.  For example, in a patient admitted with known systolic dysfunction, The problem (heart failure with systolic dysfunction) would include in the subjective comments on dyspnea, ankle swelling, chest pain, while the physical exam would include looking at the jugular veins, describing the heart and lung exams and mentioning the presence or absence of ankle edema.  It would likely ...
Source: DB's Medical Rants - Category: Internal Medicine Authors: Tags: Medical Rants Source Type: blogs