Recently a colleague reached out to ask for advice on writing clinic notes more quickly. He said he jots a few phrases during a patient’s appointment and stays at the end of the work day to write out all the day’s notes. It can add 90 minutes or more to his day. As you might imagine, he is stressed out and time-starved. He completed his residency about three years ago and feels he needs to find a better way. He maintains paper charts in the clinic and isn’t yet thinking of shifting to EHRs. One step at a time, he says.
So, today I share my approach to writing psychiatric SOAP notes quickly and effectively. I don’t believe I have any great insight but hope some of this may help. Please let me know if you have anything additional you’d recommend.
Optimizing note-writing requires including highly relevant information (for the sake of effectiveness) while excluding low relevance information (for the sake of efficiency). Of course, this begs the question of what is relevant and what isn’t.
This is how I establish relevancy of information (for the purposes of clinical decision-making and for note-inclusion): I start with the end in mind. From the moment I lay eyes on the patient coming into my office, through every question I ask and lab I order, I keep in mind the main decision I need to make: Does the patient’s treatment plan NEED TO CHANGE or NOT NEED TO CHANGE from the current one.
Knowing I must make this decision focuses me on attending to and gathering information in support (or in justification) of my change/no change decision.
• Cases requiring no change in the treatment plan:
• Patient remains asymptomatic and is functioning well
• Patient is doing well (even is some symptoms and dysfunction present) given the type and severity of their diagnosis and their history of treatment response
• For patients at risk for or with history of relapses, patient’s maintenance treatment continues to provide adequate protection in minimizing relapses. (Adequacy requires historical information related to relapses.)
• Cases suggesting a need to change the treatment plan:
• Patient not adhering to treatment
• Patient poorly tolerant of meds even if short-term adherence is adequate
• Patient not adequately responding within appropriate time frame
• Patient getting worse or risk has increased
• New symptoms/dysfunctions have arisen
• Barriers to treatment interfering with treatment (it’s too complicated, expensive, time wrong, no child care,
or interferes with work)
If it becomes clear during the appointment that something isn’t working right and needs to change, I focus on identifying the contributors to the problem and what resources are available to combat it. And, last, if the patient’s treatment plan at the previous visit was not changed because response was adequate at that time, I want to know if anything in the patient’s life has changed since the last visit, so I can address that.
Sample SOAP Note
Let me give an example of, let’s say, a note written freeform in a paper chart of a depressed patient with ongoing suicidal thoughts (so as not to make this case too straight-forward):
S: Depression: Pt “tired all the time, not sleeping well.” Mood “I’m still down … about the same.”
Suicide: Thoughts “still there. Not worse, but I get tired of thinking them so much… makes me feel like a loser.” Denies suicide plan, investigating methods, intentions, impulses. No homicidal thoughts, intents, impulses. No firearms in home or readily available. No med stashes in home.
Other: No repeat panic attacks. No psychosis. Alcohol use: denies since last visit – “Drinking makes me feels worse.”
Function: More isolative. Little structured time. Stopped preparing meals. Sometimes just eats chips.
Med: Affirms adherence. Uses pill box. Tolerating well. Open to increasing the dose.
O: Mildly disheveled, gloomy expression, voice with little energy, engagement and eye contact decreased. No smell of alcohol as before.
A: No change in diagnosis. No improvement in symptoms. Function worse. Less engaged and worse eye contact – bad signs. Denies active suicidal plan and intent, but voices fatigue with symptoms – pt at risk of giving up. Short term suicide risk remains low-moderate but longer term is increasing. Treatment changes warranted. Poor daily structure contributes.
P: 1. Increase sertraline to 150mg qd. Several adverse effects explained. If AEs severe pt to call me. If AEs mild-mod pt to slow titration.
2. Referred to Psychosocial Rehab. Needs support to re-establish meaningful daily routine and health behaviors. Obtained release – Will follow up with PSR staff next week.
3. We started Safety Plan. Pt to complete for next appt.
4. Given increased risk and treatment changes, return 1 week.
5. Repeat labs due at next month
Thoughts About Note-Taking
• If you had only read the subjective and objective sections (SO), you should have been able to anticipate the assessment and plan (AP) – if I wrote the note right. In the SO I limit information included only to what justifies my AP.
• I try to limit acronym use, especially when writing about suicide and homicide. This is a personal choice. I feel if my patient ever hurts self or others, I want to communicate to any reader that I took these symptoms particularly seriously. It’s my own self-management, I guess.
• At one point in my career I was dictating notes. I would use the format above except speak out the points in full melodious (haha) sentences.
• If you use EHR, a word of caution: if you copy and paste notes from one appointment to the next, be careful that you read them through all the way and update them fully. It is soooo easy to make changes “here and there” and inadvertently let old information sneak through; like in one section writing “Pt with new onset SI without intent or plan” while in another retaining the boilerplate “No SI/HI.”
• If you use templates for entire notes or just for parts like a templated “treatment plan for depression,” the above point remains. Make sure everything in your notes is really meant to be there.
An anecdote: several years ago I was deposed on a medical malpractice case on a former patient of mine – I was not named in the suit. The plaintiff’s attorney asked me, “Dr. Krasuski, please take a look at your note from July 18. You gave the patient a GAF of 59. What does 59 mean to you? What would you say the difference is between 59 and 60? And is that difference greater than between 58 and 59?” Then he did the same for the next two notes, which seemed fairly well written except that all three notes had the same GAF which I had failed to update. (As you can imagine, I stumbled through my answers – don’t ask me what they were. It’s a blur.) During a pause in the questioning I glanced through the rest of the printed out chart and discovered that the GAF I assigned the patient stayed at 59 throughout that entire year even though the patient’s condition had fluctuated. I wasn’t getting sued but I sure felt like an idiot. I don’t know if the attorney’s questions were necessary to the case or were asked just to highlight my … umm … errors. In any case, I became more vigilant in my EHR notes from then on not to copy outdated text.
Until next time,
“Mystification is simple; clarity is the hardest thing of all.”
– Julian Barnes
“There is clarity and beauty that comes from simplicity that we sometimes do not appreciate in our thirst for intricate solutions.”
– Deiter Uchtdorf
“Do what you want that works.”
– Toba Beta