Tuesday, August 17, 2010

Expanding SOAP to SOAPS---incorporating patient safety into progress notes

From the Journal of Graduate Medical Education:

An alternative approach, which we believe best incorporates live interaction and real-time learning while enhancing patient care and maintaining clinical applicability, is a modification of the standard SOAP (subjective, objective, assessment, and plan) case-presentation format. This option redefines the classic SOAP note to a SOAPS note, with the additional S standing for safety. This method directs providers, at the point of care, to identify potential safety issues during each encounter...

This makes sense, and I think many of us have already adopted something similar with the advent of the EMR, in the form of a check list at the end of our progress note templates, with reminders about DVT prophylaxis, pharmacovigilance, foley catheter removal and the like.

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