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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.