Effective Structure for Clerking a Patient
The SOAP (Subjective, Objective, Assessment, Plan) framework is the most effective structure for clerking patients, as it provides a systematic approach to patient documentation while facilitating effective patient-clinician communication.
SOAP Framework Overview
1. Subjective (S)
- Patient's history and symptoms in their own words
- Chief complaint and history of present illness
- Past medical history, medications, allergies
- Social and family history
- Review of systems
2. Objective (O)
- Physical examination findings
- Vital signs
- Laboratory and diagnostic test results
- Imaging findings
- Other measurable clinical data
3. Assessment (A)
- Synthesis of subjective and objective information
- Differential diagnosis
- Clinical reasoning and interpretation
- Problem list prioritization
4. Plan (P)
- Diagnostic plans (tests to order)
- Therapeutic interventions
- Patient education
- Follow-up arrangements
Best Practices for Implementation
Setting Up the Patient Encounter
- Greet the patient and any accompanying persons before beginning the interaction 1
- Position yourself to face the patient most of the time 2
- Maintain eye contact while typing or documenting 1
- Ask permission before typing notes during the encounter 2
- Explain the purpose of documentation to the patient 2
During History Taking (Subjective)
- Orient yourself to the patient's understanding and concerns: "What do you understand about why you're here today?" 1
- Use simple language tailored to the patient's educational level 1
- Avoid medical jargon and explain terminology when necessary 1
- Allow patients to express their understanding and feelings 1
- Separate typing and patient interaction - focus on the patient when they're speaking 1
During Examination (Objective)
- Explain what you're doing during the physical examination
- Maintain verbal communication while documenting findings 1
- Use verbal and nonverbal cues (nodding, "I see," "mm-hmm") while documenting 1
- Invite the patient to view relevant data on screen when appropriate 1, 2
During Assessment and Plan
- Acknowledge and name emotions when patients display them 1
- Check for understanding using "teach back" methods: "In your own words, what does this mean to you?" 1
- Involve patients in decision-making: "Let's discuss the options and decide together" 1
- Review the visit with the patient after finishing documentation 1
Enhanced SOAP Variations
Some clinicians use expanded versions of SOAP for more comprehensive documentation:
SNOCAMP: Subjective, Nature of complaint, Objective, Assessment, Counseling, Medical decision-making, Plan 3
SOAPE: Subjective, Objective, Assessment, Plan, for Equity - particularly useful for addressing diversity, equity, and inclusion considerations 4
Common Pitfalls to Avoid
- Information overload: Provide information in small doses, checking frequently for comprehension 1
- Excessive computer focus: Avoid focusing on the computer at the expense of patient interaction 1
- Delayed information sharing: Avoid unnecessary delays in providing information 1
- Ignoring emotions: When patients are emotional, be cautious about providing information as they may have difficulty processing it 1
- Poor room setup: Ensure proper positioning of computer screens to maintain eye contact with patients 1
Documentation Tips
- Document telephone encounters consistently with the same structure 2
- Review the patient's medical record before the encounter to maximize face-to-face time 2
- Use brief, short typing sessions focusing solely on the EHR when needed 1
- Consider using other aids for typing purposes when appropriate (e.g., clinic staff, transcriptionist) 1
The SOAP framework provides a logical, systematic approach to patient clerking that ensures comprehensive documentation while maintaining effective patient-clinician communication, ultimately improving patient outcomes and satisfaction.