12.4 Introduction to Medical Charting
Katie Baker
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
Sample Soap Note
S: 34 yo male, chief complaint (CC): shortness of breath, cough with exercise. Patient reports shortness of breath and cough with exercise this spring, new onset 1 week ago, only occurs with running outside. Reports tightness in chest when he began his new exercise regimen of running outdoors. Symptoms emerge with each attempt at exercise, both tightness and spasmodic cough, better after about 10 minutes of rest. He has no history of recent illness, smoking or asthma. Patient denies fever, sore throat, nasal congestion, sinus pain, digestive problems, dizziness, or lightheadedness. Patient was not very active for many years, but has been exercising regularly since college. Family history of asthma and COPD from smoking.
O: Vitals: RR: 14, HR: 64, BP 120/85, O2 Sat: 98%, EENT – WNL, Nodes – WNL, Resp – slight expiratory wheeze, RRR, Cardio – WNL, Skin – WNL, Psych – WNL
A: Diagnosis: Exercise-induced bronchospasm (J45.990); Asthma education (Z71.89)
P: Patient was advised on his diagnosis of exercise-induced bronchospasm, and 15 minutes was spent with the PA discussing treatment options and prevention. Handout on asthma was given to the patient, detailing supportive measures for exercise-induced asthma. Rx: Albuterol sulfate HSA 90 mcg inhaler. sig: 2 puffs prn (as needed). Rx: Spacer for use with inhaler; Patient to follow up in 3 months or as needed to assess treatment plan.
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.).
Skill Stitch: Creating Soap Notes
In this activity, you’ll be reading a scenario and categorizing the provided information into the appropriate sections of a SOAP note. This format helps healthcare providers communicate effectively and ensures all important information is captured clearly.
18 year old Christopher comes into your office on a sunny day, wearing sunglasses indoors and asking if you can dim the lights. He reports experiencing nausea and a headache around his left temple and the left side of his head. The pain worsens with bright lights and loud sounds but improves when he lies down in a dark room. He has tried Tylenol, which provided some modest relief. Christopher also reports a lack of appetite and finds that just smelling his favorite foods makes him feel like vomiting. He denies fever, shortness of breath, cough, constipation, or diarrhea. Christopher has no history of head injury or previous headaches.
Upon physical examination, you note that his pupils are equally dilated and less reactive to light and accommodation. There are no swollen lymph nodes, and his ear/nose/throat (ENT), abdominal, and skin exams are all normal. A brief neurological exam shows no abnormalities in balance or cranial nerve function, aside from the pupillary difference. Based on these findings, you conclude that Christopher is suffering from a migraine. To confirm the diagnosis, you instruct him to track his headache pattern and follow up in one month. You also advise him to keep a journal of any new symptoms that may arise between visits, so you can reassess the diagnosis if necessary. You prescribe Excedrin migraine for him to take for the duration of his migraine and write him an excuse for missing school.
Your plan includes considering prescription migraine medication if the migraines persist or worsen, as well as a possible referral to neurology for further consultation.
A form of medical charting that includes the following components:
Also known as presenting complaint. Medical term used to describe the primary problem of the patient that led the patient to seek out medical attention.
Abbreviation for prescription, from the Latin for “recipe”, meaning “to take”.
Abbreviation for “signetur” on a prescription, meaning the directions for how to take the medication (amount, frequency, duration, special instructions, etc).