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Excellence in medical documentation reflects and creates excellence in medical care. At its best, the medical record forms a clear and complete plan that legibly communicates pertinent information, credits competent care and forms a tight defense against allegations of malpractice by aligning patient and provider expectations.

When physicians are viewed as dispensers of advice and patients as followers of that advice, the credit or burden for clinical outcomes goes to the physician. In reality, it's impossible for physicians to guarantee particular outcomes. For better or worse, patients possess the greatest control over the behaviors and choices that affect their health.

Correlating patient expectations with likely clinical outcomes and enrolling patients in the decision-making process are early steps in preventing malpractice allegations. Effective documentation auspiciously captures these steps in a format that may derail erroneous charges or immediately exculpate the wrongly accused.

Physicians typically approach documentation with the goal of communicating effectively with themselves. This approach creates problems when malpractice allegations are made and plaintiff attorneys, arbitrators and juries engage in what is often anger- or sympathy-driven reviews of physicians' records that assume negligently omitted or committed acts in the absence of contrary evidence.

KEY POINTS:

• Supporting patient understanding of likely outcomes and including patients in decision-making can help prevent malpractice allegations.
• SOOOAAP selectively expands SOAP by embedding it with easily remembered risk-reduction techniques.
• Including informed consent within notes encourages patients to take responsibility for their choices and improves information sharing.

There is no quick and effective antidote to such allegations. The medical record should never be erased or altered, and once requested by a reviewer it cannot plausibly be amended. Rescission is impossible. Prevention is necessary. Thorough and thoughtful documentation provides paper-and-ink or screen-and-byte inoculation against miscommunication and misunderstanding. By guarding against a lengthy litigation process, it may be the ultimate time saver.

While the commonly used SOAP (Subjective, Objective, Assessment and Plan) outline serves as a template for information gathering in basic office visits, it lacks flexibility and does not encourage a more proactive approach to patient care and malpractice risk reduction. Without straying too far from the traditional SOAP format, this article offers an expandable progress note model — S-O-O-O-A-AP (Subjective, Objective, Opinion, Options, Advice, Agreed Plan). This format applies to nearly all types of office visits; prompts two-way communication, patient participation and informed consent collection; and records the patient's acceptance of responsibility for following through with the health care plan.

Expanding SOAP

SOOOAAP is not designed to replace the SOAP note. Rather, it selectively expands SOAP by embedding it with easy-to-remember, risk-reduction techniques. My purpose is to share documentation techniques that improve communication, enhance patient care and decrease your risk of being charged with malpractice.

Subjective: This section contains the patient's new or primary concern. (See “A sample SOOOAAP note.”)

• Use direct patient quotes to demonstrate your attention to patients, highlight main areas of concern, build credibility into the record and accurately document a patient's competency, affect and attitude. Not unexpectedly, a patient's self-portrayal may markedly change between the time of your encounter and the time of an appearance before an attorney or jury. For example, if during an initial visit a patient says, “I've been to 20 doctors, and no one can help me,” documenting such a remark communicates his or her attitude. Patients' abusive or threatening words will sufficiently demonstrate their level of cooperation and credibility, while removing any biases in your interpretations.
• Complete the review of systems with an inquiry such as, “Do you have any other concerns?” Documenting all concerns addressed demonstrates your thoroughness in obtaining the patient's history and avoids later charges that the patient brought an important symptom to your attention that you ignored or neglected.

Objective: This section provides a list of measurable, reproducible data, including citations from laboratory or imaging results.

• Include supportive, reproducible observations. If a child appears “nontoxic,” list the reasons that justify this description, such as “Child climbing on exam table” or “Child irritable but consolable within 10 seconds.”
• Document the accuracy of specific measures. For example, record serial weights on a dehydrated infant with “12-ounce weight loss, same scales.” If you don't take them yourself, confirm vital signs and note that you've done so. Normal adult respiratory rates are 12 to 16 breaths per minute, but the seemingly universal 20 breaths per minute listed on nursing charts and “neglected” by you on a progress note may represent overlooked respiratory distress to a reviewer.
• Because patients sometimes present with apparently abnormal vital signs that correct during their visit, when appropriate, recheck their vital signs at the end of the visit and document corrected measures.
• Perform sensitive examinations, such as breast or genital exams, with a qualified assistant present. Credit your caution and sensitivity by beginning your documentation with “Chaperoned exam of … ” and “Exam assisted by … .” Include the assistant's initials to confirm who witnessed your care. Careful documentation in this area is especially important because allegations of improper touching are criminal charges not covered under medical malpractice insurance policies.
• Avoid judgmental or potentially anger-provoking descriptors. If commenting on a patient's hygiene is necessary, replace pejorative entries such as “Needs a bath” with factual statements such as “Hair oily. Scent of body sweat present.” Include descriptions of non-medical findings that lend insight, but exclude your interpretation of their broader meanings. For example, use “Two-inch black swastika tattoo present on left biceps.” Leave it to reviewers to draw their own conclusions as to the meaning of such findings.
• Avoid embarrassing or easily misunderstood descriptors. SOB may accurately apply to a patient. However, the patient may respond to such a label with anger. Remember, the medical record belongs to the patient. It's easier to avoid using potentially confusing descriptors than to disabuse patients of solidified misunderstandings later.

Opinion: This section replaces the “Assessment” section of the traditional SOAP note. In addition to reinforcing that you've communicated the limitations of medical diagnosis to the patient, your documentation in this section should preclude absolutism and provide an impressive record of your comprehensive care.

• Avoid false certainties in diagnoses and reduce the burden of unmet expectations by accurately aligning patient hopes with likely outcomes, and document that you've done so. For example, the statement “likely gastroenteritis, appendicitis possible” preserves your open-minded approach during an initial visit with the parents of a child experiencing abdominal pain. To patients, their families and jurors, unmet expectations are the emotional equivalent of broken promises. Disappointment provokes anger. Anger precipitates malpractice claims.
• Understand that while patients may desire and appreciate immediate and firm diagnoses for their ailments, a diagnosis cannot always be given with certainty. Many people with diseases lack the “classic” features of their specific disease, and many people unfettered by a specific disease may have “classic” findings. Physical examinations, laboratory evaluations and imaging studies are better at ruling diagnoses out than ruling them in. Because of this and the revealing effects of time on treatment response, view diagnoses as works in progress and document accordingly.
• Clearly explain to your patient that the assessment is an opinion, new findings may develop, different explanations may be found and additional treatments may be necessary. Document that you've talked about this.

Options: This section, which supplements the “Plan” section of SOAP, supplies evidence of informed consent or informed refusal. Consent and refusal are choices. To choose requires alternatives. This section will prompt you to improve information sharing with your patients and encourage patients to take responsibility for their choices.

• Throughout the care process, discuss the alternatives, risks and benefits of evaluations and treatments, including a review of likely outcomes if a treatment is withheld or refused, and document the discussion.
• If you dictate your progress notes, boost patient-physician communication by dicpatient encounters. Creating a patient-witnessed, contemporaneous record reinforces consent discussions, reminds patients of recommendations and instructions, invites patient corrections and confirmation and impresses patients with your thoroughness. Just before completing a note, I often pause the recorder and ask “Is that right?” or “Do you agree?” If the patient agrees, they've confirmed their understanding and consent. If he or she does not, we further investigate their concerns and address any obstacles in understanding. This technique is also valuable in rooting out confounding issues, as patients are granted another opportunity to reveal a hidden agenda.
• In cases where a patient refuses treatment, document his or her ability to understand the repercussions of the refusal. If the patient's choice may allow serious injury or hasten death, multiple visits may be necessary to document the durability of his or her decision and eliminate other possible reasons for his or her choice. Though you may sometimes disagree with the informed choices of competent adults, you must respect them. Document in a manner that makes it clear that the patient chose to refuse treatment by using “Consistent with the patient's informed choice … .” You should also welcome and document a patient's continual right to reverse his or her decision and receive a recommended treatment.

Advice: This section distills options into the best choice for each health concern and funnels your advice into a coherent statement with supportive reasoning.

• Share your expertise and encouragement to help guide the patient's choice. Document your reinforcement of the principle that the physician advises and the patient chooses.
• Eliminate festering misunderstandings by confronting unreasonable expectations. For example, you could document “Futility of antibiotics in this situation reviewed” in a case in which you did not write a prescription that a patient thought was necessary for treatment. This approach may also prevent an adverse response to an inappropriate treatment and uncover a patient-physician relationship in need of attention. Open disagreement need not damage the patient-physician relationship, but neglected discontent spoils the engagement necessary to achieve successful outcomes.
• Document your encouragement of health maintenance and wellness. “Urged smoking cessation and offered assistance” or “Encouraged safety-belt use” are types of incidental advice we repeatedly include in patient encounters, but sometimes forget to add to our notes. Credit your thoroughness and avoid allegations of “You never told me … .”
• Protect people who are not your patients through proxy advice. “Advised to notify sexual contacts,” “Advised that household contacts need prophylaxis” or “Contagious nature of conjunctivitis reviewed” are a few examples that apply.

Agreed Plan: This section synthesizes the physician's guidance and the patient's choice into a coherent statement that the patient understands and agrees to follow.

• Document goals or expected outcomes and specify a time frame for reaching them. Include interval instructions in case of changes in the patient's condition. For example, “Recheck if not better in five days, sooner if worse.”
• Complement a concise statement of the agreed plan with a statement such as “Patient understands and agrees,” which seals the patient's accepted responsibility into his medical record.
• Anticipate possible serious adverse outcomes, teach your patients to notify you if they occur and document that you've done so. Inform patients of your practice's 24-hour, 365-day access policy, and advertise it in your notes. “Patient knows to call any time if an emergency arises” reminds reviewers of the tremendous efforts you expend on the patient's behalf.
• When medications (including alternative therapies) are prescribed, review their known common and severe side effects. Encapsulate lengthy medication risk reviews in the notation by stating “… with warnings.” For example, “Prescribed lisinopril 10 mg with warnings, #30, 5 refills.”
• Without necessarily discouraging their use, address patient-prescribed treatments with “Communicated that risks and benefits of self-selected treatments not wholly known.”
• Document follow-up arrangements with “Patient agrees to follow up” or “Patient states he'll keep appointment.” If a patient breaches an agree-appointment, boldly note this and your progressive attempts to re-establish patient care.

A sample SOOOAAP note

Subjective: 41-year-old white female states, “I felt a lump on my right breast yesterday.” Lump is nontender without pruritus, bleeding or nipple discharge. No associated fevers, chills, fatigue, weight change, hot flashes, back or joint pains. No personal or family history of breast cancer. Menarche at age 13, mother of three, first born at age 22, all breast fed to age 1 without problems. Normal LMP three weeks ago, contraception via condoms, infrequently performs BSE, drinks three to five cups of coffee daily, nonsmoker. No other concerns today.

Objective: Chaperoned exam by nurse A.C. BP, 120/70; P=66; RR=14; T=99.2 oral; weight=138 lbs. Lungs clear bilaterally, Heart RRR, no palpable vertebral tenderness or spinal deformity. Breast without skin color or texture change, no retractions. Left breast without nodularity or expressed discharge. Right breast with 1.5 cm, mobile, smooth-bordered, rubbery, nontender lesion at 10 o'clock. No other lesions. No nipple discharge. No axillary lymphadenopathy bilaterally.

Opinion: Right breast lump. Specific diagnosis unclear. History and exam favor fibrocystic change. Rule out malignant involvement.

Options: Reviewed observation with re-examination through full menstrual cycle vs. ultrasound with possible biopsy. Symptomatic treatments reviewed including caffeine reduction and hormonal stabilization with OCPs.

Advice: Advised ultrasound characterization now with possible follow-up investigations including biopsy and/or excision. Tripartite nature of breast cancer reviewed. Encouraged annual screening mammography and reviewed its diagnostic limitations. Instructed BSE. Reminded patient she is due for lipid profile.

Agreed Plan: Patient chooses ultrasound now. Radiology appointment scheduled. She understands need for close follow up and states she'll keep appointments. Recheck in one week. Dictated in patient's presence.

A better defense

Successful clinical care is a collaborative activity with shared responsibilities. The patient and physician work together to learn about the patient's illness and concerns, review the diagnostic and treatment options and enact a patient-chosen plan. Medical documentation records this shared effort. By applying the refined SOOOAAP techniques, you will stimulate patient-physician communication, align expectations and fortify malpractice defenses. Building these memorable communication prompters into a contemporaneous documentation system shepherds your patient encounters toward complete information sharing and improved clinical outcomes.

Like the system it supplements, the SOOOAAP method of medical documentation functions without empirical support for its efficacy. Users of any documentation system must be aware that given the emotion-laden, commerce-driven nature of litigation and the complex and capricious interpretations of malpractice, no system of medical documentation will eliminate malpractice allegations.

Physicians may reduce their risk for such allegations by adhering and updating to appropriate standards of care, open-mindedly approaching evaluations, fostering and respecting patient choices and revising their view of documentation from a necessary chore to an opportunity to credit the excellent care they provide.