The topics for this post 🕯️are electronic health records (EHR) and "SOAP" notes. 💫
At Candle, we believe medical records are vital to both the legal industry and humankind at large. And because we are nerds, we wanted to share some insight on medical records generally. (nothing in this post is medical or legal advice) 😀 An electronic health record (EHR) is an electronic system which captures and stores personally identifiable health information about patients. 🗓️ The lionshare of personal health information (PHI) in EHRs is recorded by a range of health care providers (EMTs, nurses, nurse practitioners, physicians, etc). 🦁
One common way medical providers organize a patient’s record is in a “SOAP” note, which stands for “Subjective, Objective, Assessment, and Plan.” ✨ The SOAP acronym describes the flow of information most patient notes follow. ✅
S The “Subjective Portion” includes what is known as the “History of Present Illness,” or HPI for short. You can think of the HPI as the story 📚 of what brought the patient into the clinic (like an injury) plus any pertinent past medical, surgical, or family history of illness (think priors).
O After the HPI has been recorded, the provider will gather data in three additional “Objective” ways: 1) physical exam, 2) laboratory tests, and 3) imaging.
A Once all the subjective and objective data has been gathered, the “Assessment” in SOAP can begin. At this point, a “differential diagnosis” is made ⚖️. This means a few – generally three – of the most likely diagnoses are written down, from which the provider will justify what they believe explains the presenting symptoms the best.🏥
P After the assessment has been made, a "Plan" is made based on the final assessment. This includes treatment (if applicable) and management.💊 Now we have walked through all the sections of a “SOAP” note, which is a common way patient health information (PHI) is organized in electronic health record (EHR).
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