Chapter 12: Communication
Katie Baker
Medical charting is the paper or electronic record of the patient’s relationship with the medical organization. This can include patient visit notes, lab results and imaging findings as well as correspondence between providers on the patient’s healthcare team and from the patient and authorizations and other communications from the patient’s third party payor, whether government or private insurance carrier.
Many electronic records have the additional benefit of being shared between healthcare providers as well as providing greater ability to utilize patient data for research. However, to ensure that records are effective they need to include sufficient information, a quality referred to as “meaningful use”. The “Meaningful Use” standard refers to the utilization of medical records in a way that improves quality, safety and efficiency, engages patients and families, improves coordination of care and public health, ensures privacy and reduces health disparities” (Androus, 2023). Practices that use electronic records can qualify for financial incentives to support their adoption. Eligibility for these incentives requires that a provider’s patient loads include a certain percentage of Medicare or Medicaid patients. Providers must meet goals for completion of specific objectives during a majority of their Medicare or Medicaid patient visits. These objectives involve completion of charting components that are intended to ensure their electronic medical charting is complete and provides improvements in healthcare outcomes. Since collection of meaningful use data for these incentives also requires that a certain percentage of patients fall under Medicare or Medicaid coverage many providers will not have patient loads that ensure eligibility, even as they are completing the required charting components.
Medical charting is a legal document and as such can be used in a court of law to determine outcomes of legal cases. So it is very important that charting is accurate, legible and specific. Charting will need to be retained for 7 years in the state of Washington. Destruction of charting must be done through an approved method (such as shredding of documents or removal of electronic charting by an approved company for medical charting disposal).
Paper Vs. Electronic Charting
Paper charting has begun to give way to electronic charting (also known as electronic healthcare records, or EHR) after hundreds of years of use. Both paper and electronic charting have pros and cons. In the section we will discuss the benefits and detriments of both.
Paper charting requires physical storage and supplies such as filing cabinets or bookshelves, file folders, dividers, metal tabs, writing implements and chart stickers but purchasing these may be less expensive for a new practice then an investment in most electronic charting systems Paper charting will also require office staff to make physical copies for mailing and faxing records, as well as printing electronic communications and lab results. Included in the costs associated with paper charting, new offices must include the costs of mailing, printing and faxing, including stamps, envelopes, printer ink and a possible dedicated phone line for a fax machine or a scanner for sending paper records to an electronic system destination. However, paper charting is exempt from issues that affect computer access such as Internet disruptions, hardware and software update requirements and malicious cyberattacks.
While electronic charting requires a more significant investment up front, storage costs tend to be much lower when using the cloud or an online server compared to the cost of physical storage and supplies for paper charting. In addition, most electronic charting software allows for communication between different major software programs that may be used by different healthcare organizations. Utilization of a common format in electronic charting allows for ease-of-use and more rapid engagement once visit templates have been created and uploaded. Reducing transcription errors (compared to handwritten chart notes) and minimizing provider paperwork are two other benefits of electronic charting. Electronic charting can be seamlessly integrated into electronic coding and billing, providing an easier process for providers to get paid by third-party payors. In fact, the movement towards electronic health records was part of a mandate by President G.W. Bush in 2004 in an effort to reduce medical errors.
All in all, paper charting is now almost exclusively used by solo and small group practices while electronic charting has been embraced by healthcare corporations, hospitals, and many Medicare and Medicaid providers.However, if the electronic system goes down, technical issues arise with a computer or the power goes out, paper charting is still used as the fall-back process to allow patient care to continue.
SOAP Medical Charting
Whether in an electronic or paper form, the details of a patient visit can be recorded in many different forms. One common form is referred to as soap notes. below, you can see what the letters S, O, A and P stand for in the acronym:
(S) Subjective
This is where you will note the information that the patient tells you regarding their concern for their visit. In this area, one would include information about the patient’s chief complaint, including information about the history of their present illness, any medications they are taking, allergies that they currently have, their past medical, family, and social history, and a review of their body systems for any other concerns.
The history of present illness, or HPI, can explain what a patient is experiencing and provide a starting point for clinicians to diagnose and treat. It includes questions about the onset, location, and duration of the chief complaint, a characterization or description of it (for example, is the pain burning or throbbing), and whether the condition radiates to different parts of the body or changes at different times of day (stomach pain that is better after eating might lead a provider to a different conclusion than stomach pain that occurs with food). Finally, the patient can mention any treatments they have been doing on their own as well as any things that make their condition better or worse and the overall severity rating in their opinion (such as on a pain scale from 1-10).
(O) Objective
The objective component of charting includes information that the provider observes or that is discovered through physical examination, lab tests, imaging or other procedures. This is considered objective because it is not filtered through the memory of the patient but is observable and quantifiable. Vital signs and pertinent medical exam findings would be included here for office visits. In this section, you will frequently see the abbreviation “WNL”, which stands for “within normal limits” or no abnormalities noted.
(A) Assessment
The assessment component involves the likely diagnosis including ICD-10 code. In this section you may also see diagnosis and their codes for chronic conditions or secondary complaints. You may also see codes to support certain interventions (for example codes for counseling on specific topics, like nutrition or STI prevention). Occasionally, providers will include a differential diagnosis in this section to refer back to in future visits if the original assessment and diagnosis are incorrect.
(P) Plan
The plan component includes information about tests, Imaging and other procedures that are being ordered by the provider, medications that are prescribed as well as their dosages and durations, home treatment plans for the patient and occasionally future plan section that includes next steps in diagnosis and/or treatment of the complaint.
Sample Soap Note
S: 34 yo male, CC (chief complaint): shortness of breath, cough with exercise. Patient reports shortness of breath and cough with exercise this spring, new onset one 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 sx, dizziness or lightheadedness. Patient was not very active for many years, but has not 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, 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
The SOAP note format was created over 50 years ago and still remains popular, although it is occasionally redesigned as APSO or SOAPIER, which includes Intervention, Evaluation and Revision. Other forms of charting include narrative recording where the nursing provider will create a diary entry-style note, charting by exception (CBE) which only includes abnormal findings and leaves out normal ones, PIE charting (P for Problem, I for intervention and E for evaluation) and Focus or DAR (data, action, response) charting (Correll, 2020). Regardless of the type of chart use, all notes should include the author’s name and the date of the visit. Medical charting for a visit should be completed within 24 hours of the visit and will require a provider signature at the bottom to attest to the accuracy and completeness and to prevent unauthorized additions after the fact. Addenda may be used when more information comes to light between visits.
Computerized Provider Order Entry (CPOE) is a widely-used electronic medical charting process used to provide information about a patient’s treatment, such as prescriptions. It is widely used as a part of EHR that can be utilized by providers, nurses, MAs and non-credentialed staff that helps to reduce ordering and pharmacy errors. Use of CPOE is required for Medicare Meaningful Use data recording for Medicare incentive programs that pay medical facilities grant money for improving or implementing medical charting in a way that allows for the collection of data and for the reduction in medical errors (American Medical Association, n.d.).
Skill Stitch: Creating Soap Notes
In this activity, you will read a short scenario and try to place the different pieces of information in the proper section of a SOAP chart. Do your best and you’ll soon see how doctors and other providers can consistently communicate with this format, making it easy to find information and communicate clearly! Don’t forget! You can review Section 12.4.2 for a reminder on what the SOAP format contains and an example of a scenario with a filled SOAP note.
18 year old Christopher comes into your office on a sunny day, wearing sunglasses inside and asking if you can turn down the lights. He reports a strong sense of nausea and pain in his head around his left temple and left side, which is made worse with bright light and loud sounds and better lying down in the dark. He has tried Tylenol and found some modest relief. Christopher reports not feeling very hungry and finding that just smelling his favorite foods makes him feel like throwing up. He denies fever, shortness of breath, cough, constipation or diarrhea. Christopher has no history of head injury or past headaches.
Upon physical exam, you note that his pupils are equally dilated and less reactive to light and accommodation. You find no swollen lymph nodes, your ear/nose/throat (ENT), abdominal and skin exams all give normal findings. Your brief neurological exam shows no abnormalities in balance or cranial nerve changes (aside from the pupillary difference). You conclude that Christopher is suffering from a migraine. To be sure, you will ask him to track his headache pattern and to follow up in one month. You also ask him to journal about any new symptoms that come up between visits so you can reassess your diagnosis, if necessary. You prescribe Excedrin migraine for him to take (as directed) for the duration of his migraine and write him an excuse for missing school.
Your future plan includes considering prescription migraine medication if migraines continue or worsen and a possible referral to neurology for a 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).