Are useful notes in our future – the return of SOAP

CMS is changing note requirements, among other changes.  Bob Doherty has a wonderful summary – FOUR things you should know about Medicare’s “historic” changes to physician payments As always, we really will have a difficult time sorting out the unintended consequences of these changes, but they certainly seem like a move in the proper direction.  To me the most important change is a focus on notes – “allowing medical decision making to be the basis for documentation, requiring physicians to only document changed information for established patients and to sign-off on basic information documented by practice staff” Hopefully we will begin to teach and expect Larry Weed’s SOAP notes as taught in the early 70s.  Here is an example of a totally fictional hospital note that I might have written in 1975. #1 Hyperglycemia S – no complaints O – glucose lowered from a high of 800 to 150.  Patient had 2 hypoglycemic episodes.  Anion gap remains normal (I might include the BMP here).  Normal phosphate A – Glucose easily lowered.  Patient had hyperosmolar nonketotic syndrome.  Potassium and phosphate remain normal. P – switch from IV insulin to scheduled long acting insulin and short acting with meals.  Will reinstitute his prescribed 25 u glargine daily with 5 u regular with each meal #2 Confusion S – no longer confused O – alert and oriented x3 A – problem resolved – likely secondary to gluco...
Source: DB's Medical Rants - Category: Internal Medicine Authors: Tags: Medical Rants Source Type: blogs