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 also include the current medication list, EKG, chest X-ray, echocardiogram, previous cardiac procedures, etc. The assessment would describe our interpretation of the current status of his heart disease and volume status. The plan would describe medication changes, test orders, need for a consult.
While not every note addressed the problems completely, generally the notes contained much information than our current notes. We understood the genius of Larry Weed’s change in our patient notes.
I have wondered how he would interpret the degradation of his ideas. We can blame the electronic medical record. We can blame CMS and their arcane billing requirements. Patient care suffers in my opinion. Larry Weed helped us work on the thought process. We need to once again reinvent the note to value the thought process and the careful recording of our thoughts.
Rest in peace, Larry Weed. I never met you or saw you in person, but I had great respect for you throughout my medical career.
Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.
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