Understanding clinical notes
This article:
- Breaks down the types of notes a clinician will write on you.
- Identifies key features of clinical notes.
- Highlights the benefit of reading clinical notes about you.
A health record is made up of many different documents that serve many purposes. It can be:
- A record of visit, capturing the clinician’s subjective and objective findings, observations, diagnoses and recommended treatment plans,
- A tool for providers to communicate with one another, or
- A legal document to assist in providing information to health plans, insurance and other payers for billing purposes or demonstrating a provider’s actions if questioned by a regulatory body or patient [1].
One of the most common forms of documentation are Clinical Notes or Progress Notes. These are written or dictated text outlining the interaction a clinician has with you.
You might have noticed letters like O and S appearing throughout your clinical notes. Physicians, specialists, nurse practitioners, nurses, registered practical nurses, allied health, etc. all have regulated requirements to document clearly, succinctly, and accurately. Often these will follow a common pattern using acronyms such as SBAR, SOAP/APSO, or CAPS. Clinicians don’t always use every letter in documentation.
Here is a summary of each of these letters and what they mean in relation to the acronyms.
SBAR
S (Situation):
Information about the patient themselves and/or the reported issue.
B (Background):
Any information leading up to the situation. Often details of what the patient reports to the clinician will be included.
A (Assessment/Analysis):
Any physical or verbal analysis performed by the clinician, and may also include any procedure, imaging or blood results.
R (Recommendation):
The outcome of the interaction based on options provided.
SOAP/APSO
S (Subjective):
The clinician’s discussion with a patient and/or family and the patient’s Chief Complaint (CC) or History of Present Illness (HPI). Essentially, this is the reason for the patient’s visit or hospitalization and can be lengthy depending on the patient’s experience leading up to the visit [2].
O (Objective):
Data gathered through observation and measurements, such as vital signs (height, weight, blood pressure, etc.), physical exam, laboratory results, or imaging. Often based on a head-to-toe assessment, which dictates the general order of subheadings in the note and literally moves from head to toe.
The following order of systems is often followed when reading notes: general, skin, head, eyes, ears, nose, throat, neck, respiratory, cardiovascular, abdomen/gastrointestinal, extremities, and neurological.
A (Assessment):
How the clinician assessed the situation and the patient’s condition, based on the subjective and objective data. Generally written in descending order of the severity of symptoms and may also include hypothetical language [2]. This documentation may not be conclusive and might merely validate reasons for further tests and/or procedures.
P (Plan):
Outline the next steps to be taken to treat the patient’s concern based on the assessment. This may include procedures, tests, referrals, medical imaging, prescriptions, directions or monitoring as recommended by the clinician.
CAPS
C (Concern):
The main reason the patient is presenting to the clinician.
A (Assessment):
The diagnosis with clinical reasoning as to the clinician’s thinking.
P (Plan):
An outline of the next steps and actions to be taken.
S (Supporting Information):
Subjective and objective information based on the clinician-patient interaction [3].
Understanding how clinicians commonly document your visit, will provide insight into how your doctor was thinking at the time of documentation. It can also guide you to correct terminology for bodily systems or examinations, even if the subject matter seems difficult to understand [2]. Using supporting documentation may also aid you to understand the documented notes and how they relate to your health as a whole.
References
[1] J. R. Wahl, “Abbreviations, charting and malpractice: Be careful what you write,” Healio, February 2007. [Online]. Available: https://www.healio.com/endocrinology/practice-management/news/print/endocrine-today/%7Bf44e1022-2a85-40bb-9b41-62f0c013acaa%7D/abbreviations-charting-and-malpractice-be-careful-what-you-write. [Accessed 17 May 2018].
[2] The American Translators Association, “SOAP Notes: Getting Down and Dirty with Medical Translation,” The ATA Chronicle, 2018. [Online]. Available: http://www.atanet.org/chronicle-online/cover-feature/soap-notes-getting-down-and-dirty-with-medical-translation/#sthash.LV1hiAaJ.dpbs. [Accessed 17 May 2018].
[3] P. Evans, “The Evolution of Office Notes and the EMR: The CAPS Note,” Cleveland Clinic, 8 August 2017. [Online]. Available: https://consultqd.clevelandclinic.org/the-evolution-of-office-notes-and-the-emr-the-caps-note/. [Accessed 17 May 2018].
