Part 2: The SOAP Note - A Brief History and Application to Global Health
The SOAP note (an acronym for subjective, objective, assessment, and plan)is a methodology for documenting a patient's condition on first examination by a medical professional. It serves as an excellent cognitive framework for medical professional to assess their patients.
The SOAP Note originated from the early work done by Dr. Lawrence Weed (an American physician, researcher, educator, entrepreneur and author, who is best known for creating the problem-oriented medical record as well as one of the first electronic health records).
SOAP notes are commonly found in Electronic Medical Records as a means to succinctly communicate patient information in a standard format and are particularly useful between hand-offs between medical professionals.
Modern Electronic Health Record (EHR) Systems offer a great deal more in terms of adding additional diagnostic information as well as a longitudinal patient record but the basics SOAP note could prove immensely valuable as we think about how to design a system that can empower Community Health Workers (CHWs).
SOAP Note in Practice (highly simplified for an illustrative example)
Situation: A medical professional encounters an individual who seeks or is identified for medical care
Subjective data collection
Shaking chills
Muscle ache
Fatigue
Objective data collection
Fever of 102 F (using a Bluetooth connected thermometer or a cell phone camera based temperature detector)
Malaria Rapid Diagnostic Test (RDT) administered - shows positive
Assessment
The Subjective and Objective information is collated in the medical professionals mind and and she assesses that the patient shows indications of Malaria
Plan
Based on the Subjective and Objective and informed by the Assessment, the medical professional develops a Plan that is specific to the situational context - in this case it may involve sending the patient for a confirmatory Malaria confirmatory test or in some cases starting them directly on anti-malarial treatment.
The SOAP note allows a complicated problem to be broken down into components to then become a simple problem. However, in Global Health today, this complicated problem is treated as a complex problem (See Part 1: The SOAP Note - moving from Complex to Complicated to Simple) because it is felt that only a doctor with decades of experience and a medical degree would be able to accurately diagnose and treat Malaria.
