Why I hate the SOAP note

Medicine, like law, the military, and many other professions, has its own language–a kind of verbal secret handshake by which its members recognize one another and close ranks against outsiders.

Sometimes, the use of technical terms, abbreviations, and other forms of jargon can impair patients’ understanding of their medical care. This article discusses the extent to which clinicians overestimate patients’ “health literacy“–with potentially dangerous results.

But sometimes, medical lingo has a more subtle negative effect: it reinforces our false sense of being less human, less fallible than our patients.

Certain words and phrases, used commonly in the hospital and clinic, have always set my teeth on edge. One is using “male” and “female” to describe people, as if they were specimens rather than men and women. Another thing that gets on my nerves is referring to the patient unable to describe his symptoms clearly as “a poor historian.” The “historian,” as an old professor of mine used to point out, is the person who writes down what happened and interprets it: i.e. the doctor, not the patient.

But the convention I really hate is the SOAP note. “SOAP” stands for Subjective, Objective, Assessment, and Plan. It’s the format often used for daily progress notes in a patient’s hospital chart, taught to every medical and nursing student.

I’m okay with the “assessment” and “plan.” It’s the “subjective” and the “objective” I have trouble with. You see, the patient’s experience (“I feel better” “I feel lousy” “I have chest pain”) is assigned the “subjective” role, while the clinician’s view is considered “objective.”Are these designations fair? Are they accurate?

Take a patient I saw recently. She had a rubbery, marble-sized lump on one side of her neck. I knew, with certainty, that this lump was a benign lymph node, likely inflamed because of a minor skin or throat infection. She knew, with equal–perhaps even more–certainty, that the thing had popped up out of nowhere, that it hurt, and that her sister’s cancer had started in exactly the same way.

My certainty was based in my knowledge of anatomy and physiology and my clinical experience. Her certainty was based on the sensations of her own body and on her life experience. Was either free of objectivity, or subjectivity?

Good medicine always involves a collaboration between the clinician’s and patient’s perspectives. But, as yet, there’s no nifty acronym for that.

Suzanne Koven is an internal medicine physician who blogs at In Practice at Boston.com, where this article originally appeared. She is the author of Say Hello To A Better Body: Weight Loss and Fitness For Women Over 50

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  • http://twitter.com/ChrisJohnsonMD Christopher Johnson

    I also hate the SOAP format and never use it. For me, it gets in the way of clear thinking, mainly because everything has subjective and objective components — separating them is artificial.

  • http://dr-souz.blogspot.com/ Dr Souz

    Subjective refers to patient reported symptoms.

    Objective refers to confirmable signs, lab results, imaging, etc.

    So when you say “She had a rubbery, marble-sized lump on one side of her neck.” Rubbery is objective (assuming you have felt many firm vs rubbery nodes and you’ve confirmed you get the same answer as your colleagues and you get the same answer every time). Marble-sized is objective, but your lack of precision makes the information worth less. The fact that you don’t have a precise size measurement shows that we shouldn’t put much weight in that objective measure (because marble-sized can mean different things to different people). You’ve used a subjective TERM to weaken an objective FINDING.

    Where was the node? that’s objective information. You should include it.

    What did the node look like on ultrasound? That’s objective

    What did the node look like on FNA biopsy? that’s objective

    What did the node feel like to the patient? thats subjective. You can’t reproduce the result.

    Saying “I knew, with certainty, that this lump was a benign lymph node” is not objective or subjective, it’s folly. You aren’t certain. There is a chance you are wrong. Your ASSESSMENT, which is based off of a combination of subjective and objective measures is its a benign lymph node. This premature closure, where you say you’re certain, is dangerous and your imagining of “objective” and “subjective” as a matter of expertise rather than replicability is off base.

  • http://www.facebook.com/people/Michael-Rack/100001703895437 Michael Rack

    separating subjective from objective is difficult in psychiatry. I agree with Dr. Souz’s comments when it comes to general medicine.

  • Dr. Olivia

    I simply think SOAP is a good way of summarizing patients’ clinical state

  • lauramitchellrn

    I don’t like or dislike SOAP charting, but I have to say I agree with using man or woman, rather than male or female. I used to work in OB in a teaching hospital and I would get a chuckle when the medical students presented a patient to the resident. They invariably said something like, “The patient is a 21 year old female.” I pulled one aside once and told him he didn’t need to add the “female” part: this is OB and ALL our patients our female.

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