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Wednesday, October 2, 2013

History can be Anything or "Patient Reported" ≠ "Subjective"

One of the classic forms for provider notes uses the acronym SOAP.  I always wondered where "History" fell.  In the notes I see being created, it's most often somewhere between the subjective [chief] complaint / reason for visit and history of present illness, and before review of systems, although sometimes it follows that.  Inevitably the medications, allergies, family and social history are almost always before the physical examination.

It's pretty obvious that you need to gather the information that's going to guide your future activities before you start those activites.  Right?  Right.

The challenge of the acronym is the subtle distinction between Subjective and Objective. The former is individual, inconsistent between observers (unrepeatable), opinion.  The latter is repeatable, observable, measurable, facts.  The classification of patient reported as "subjective" simply isn't fair.  Some of it is.  Some of it isn't, and is in fact quite verifiable. Past medications, diagnoses, allergies, et cetera.

Clinician assessments are sometimes just as subjective.  Terms like comfortable, or slight, or pleasant convey something of the physicians opinion of the overall appearance, but they aren't any less an opinion than a patient's statement of how they feel.

So let's forget SOAP and move to SHOAP.  History is after all, just a collection of what happened in the past, be it subjective, or objective, or assessment or plan.  How many times has physician put what you wrote down in your history as a problem or medication in your chart?  How did that act make it any more or less objective?  It didn't.


P.S.  I came up with a new acronym for this style of reporting, but I think the debate about it would be far too confusing for those of us who have to cross the IT boundary.

  • Reported -- This is what I was told.
  • Established -- This is what I determined by observation or test.
  • Summation -- This is how I sum it up
  • Treatment -- and as a result, how the patient and I think he/she should be treated.


  1. Not sure if this is funny or sad, but what popped into my head after reading this:

    U - Understand as much as you can in a ten minute visit
    S - Send the patient away confused
    A - Argue with their payer to get reimbursed

  2. Friends all nice post I also share with you something. Make your treatment theatrical. Make your customer feel as if they have been listened to, been taken seriously, and then had lots of effort made on them to create a cure. This will ensure any available placebo effect is maximised. People will feel better about themselves if you make the effort. We know that the more dramatic the intervention, the greater any placebo effect will be. So, spend at least an hour with your customer, asking lots of detailed questions, just like a homeopath. Use arcane terms and be thoroughly paternalistic, just like an old-fashioned doctor. Wear a white coat and have a brass plaque outside your spick and span clinic – just like a chiropractor. Get an impressive Harley Street address. Use equipment with dials and flashing lights. Take x-rays. Put certificates on your wall and, if you are doing well, have attractive receptionists. Give the impression you are creating your cure just for this patient. They are special. Make them feel so.
    RAKMASU Sheikh Saud Ras Al Khaimah