Medical charting is the paper or electronic record of a patient’s relationship with a healthcare organization. This includes visit notes, lab results, imaging findings, and correspondence between healthcare providers on the patient’s care team. It also encompasses communications from the patient, authorizations, and interactions with the patient’s third-party payer, such as government programs or private insurance carriers.

Many electronic records offer the added benefit of being shareable between healthcare providers and can also support research efforts. However, to ensure that records are effective, they must include sufficient information, a quality referred to as “meaningful use.” The “Meaningful Use” standard refers to the use of medical records in ways that enhance quality, safety, and efficiency, engage patients and families, improve care coordination, support public health, ensure privacy, and reduce health disparities (Androus, 2023). Practices that adopt electronic records may qualify for financial incentives, provided a certain percentage of their patients are covered by Medicare or Medicaid. Providers must meet specific goals during a majority of these patient visits, which involve completing charting components that enhance healthcare outcomes. However, many providers may not qualify for these incentives, even if they comply with the necessary charting components, as their patient loads may not meet the eligibility threshold.

Medical charting is a legal document and can be used in court to determine the outcomes of legal cases. Therefore, it is crucial that charting is accurate, legible, and specific. In Washington State, charting must be retained for at least 7 years. When it is time to destroy records, the process must be done using an approved method, such as shredding paper documents or securely removing electronic records by a certified company for medical chart disposal.

Paper vs. Electronic Charting

Paper charting, which has been in use for hundreds of years, is now largely being replaced by electronic health records (EHR). Both systems have their advantages and drawbacks, which we’ll explore here.

Paper charting requires physical storage space, such as filing cabinets, shelves, and dividers, as well as supplies like folders, pens, and chart stickers. While the initial costs may be lower for a new practice compared to investing in an EHR system, there are ongoing costs associated with printing, mailing, and faxing records, including supplies like stamps, printer ink, and a dedicated fax line. Furthermore, office staff must handle the manual work of printing, copying, and organizing documents. However, paper charting is not affected by issues like Internet disruptions, software updates, or cyberattacks.

Electronic charting requires a more significant upfront investment but offers lower long-term costs, especially with cloud storage or online servers. EHR systems allow for easy communication between different healthcare organizations, thanks to common data formats. Once visit templates are uploaded, EHR systems improve efficiency and ease of use. They also reduce transcription errors (compared to handwritten notes) and streamline administrative tasks, such as coding, billing, and payments from third-party payers. The shift toward EHRs began with President George W. Bush’s 2004 mandate to reduce medical errors through better technology.

While paper charting is still common in solo and small group practices, large healthcare organizations, hospitals, and many Medicare and Medicaid providers have embraced EHRs. However, in the event of a system failure, technical issues, or power outages, paper charting serves as a backup, ensuring patient care continues without interruption.

SOAP Medical Charting

Soap notes are a standardized method for documenting patient visits, whether in electronic or paper format. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan, each of which serves a specific purpose in the medical record.

(S) Subjective

The Subjective section captures the information provided by the patient about their condition. It includes the patient’s chief complaint, a detailed history of their present illness (HPI), current medications, allergies, and relevant medical, family, and social histories. A review of systems is often included to identify any additional concerns across different bodily systems.

The HPI focuses on the patient’s experience and provides important diagnostic clues, including:

• Onset, location, and duration of symptoms
• Characterization of symptoms (e.g., burning, throbbing pain)
• Whether symptoms change at different times of day or after certain activities (e.g., pain that improves after eating)
• Self-treatment attempts and their effectiveness
• Severity ratings, often using a pain scale (1-10)

(O) Objective

The Objective section includes observable and measurable data gathered during the visit. This can involve:

• Physical examination findings
• Vital signs (e.g., blood pressure, heart rate)
• Lab test results
• Imaging findings (e.g., X-rays, MRI scans)
• Procedures or other diagnostic evaluations

This information is considered objective because it comes from the provider’s direct observations or diagnostic tests, not from the patient’s recollection. You will often see “WNL” (within normal limits) to indicate that no abnormalities were noted.

(A) Assessment

The Assessment section outlines the likely diagnosis, often including the corresponding ICD-10 code for billing and tracking purposes. Here, providers may also note:

• Diagnoses for chronic conditions or secondary complaints
• Relevant codes for any counseling or interventions (e.g., nutrition or STI prevention)
• A differential diagnosis: possible alternative diagnoses to consider if the current assessment is incorrect

(P) Plan

The Plan details the steps to address the patient’s condition moving forward, including:

• Tests and imaging to be ordered
• Medications prescribed, including dosages and durations
• Home treatments or lifestyle recommendations
• Future follow-up appointments or next steps in diagnosis and treatment

Additional Styles of Medical Charting

While the SOAP note format remains one of the most commonly used methods for documenting patient visits, several alternative charting styles are used in different healthcare settings, each with its own benefits and specific use cases. These styles ensure that patient records are clear, concise, and tailored to the needs of healthcare providers. Below are some additional styles of medical charting (Correll, 2020):

• APSO or SOAPIER: An extension of SOAP that includes Intervention, Evaluation, and Revision
• Narrative recording: A diary-style entry created by the provider
• Charting by exception (CBE): Only includes abnormal findings
• PIE charting: Problem, Intervention, and Evaluation
• Focus or DAR charting: Data, Action, Response

Regardless of the charting style used, all notes should include the author’s name and the date of the visit. Medical charting should be completed within 24 hours of the visit and must include the provider’s signature to attest to the accuracy and completeness of the record and to prevent unauthorized additions after the fact. Addenda may be used to include additional information discovered between visits.

Computerized Provider Order Entry (CPOE) is a widely-used electronic medical charting process that provides information about a patient’s treatment, such as prescriptions. As part of electronic health records (EHR), CPOE can be utilized by providers, nurses, medical assistants (MAs), and non-credentialed staff to help reduce ordering and pharmacy errors. The use of CPOE is required for Medicare Meaningful Use data recording, a program that incentivizes medical facilities with grants for improving or implementing medical charting systems that allow for the collection of data and the reduction of medical errors (American Medical Association, n.d.).