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Back in 1968, Lawrence Weed published the princeps paper for :
1. The POMR
2. The SOAP descriptive pattern.
The SOAP pattern has been extensively used since then, in many environments.
However a growing concern is perceptible about its validity, especially among the ICPC afficionados.
The concerns focuses on :
1. the "S"
"Subjective" does not seem relevant to describe the patient's demand for care.
Many tend to use "Reason for Encounter" instead (be it subjective or
objective); note that it may also be initiated by the HCP and not by the
patient alone).
It is this way that ICPC works, after all.
Some would even rather put "Medical History" there, which in my view is
excessive, because it is of a different nature.
2. the "O"
It looks very difficult to summarize in a consistent way. For instance,
does it encompass the results of the procedures performed during the
encounter, or does it record only their performance and their intention ?
3. the "P"
It is more and more widely accepted that what is performed during the
encounter must be clearly quoted separately from what is planned or
prescribed outside its time span.
As suggested above, what is performed during the encounter may be part of
the "O" process, or --if therapeutic-- should not be confused with actions
which no one knows at that time whether they will really take place at all.
In brief, some variants of the SOAP appear here and there, and it looks
that time has now probably come to investigate the ways to deal with this
issue.
Otherwise we are at danger to be unable to make comparative study
(epidemiological or not) in the future, since all structured data will not
be structured the same way.
I look forward to your ideas on the matter.
It might even be useful to set up a workshop on the issue.
Best regards.
François
Answer from Georges Parkerson
Maybe we could have a SOAP session during the WONCA Classification
Committee meeting in Durham.
George Parkerson
Answer from Marc Jamoulle
In fact SOAP is the first conceptual step toward the structuration of clinical encounter and clinical information. Since Weed
we have worked a lot but some items are still not clear. ICPC is a classification but also a way manage information in a
structured way following the steps of Weed.
next thinking for next days
marc J
Answer from Graeme Miller
Mon, 18 Jan 1999
Francois' email raises a wider issue than SOAP.
Defining the sub
contexts of consultations/encounters is one fragment of the
data"model" of the business of general practice. The Australian
Institute of Health and Welfare has developed a National Health Data
Model at a high level and other agencies are developing data models
at a lower level closer to the clinical interface with patients.
These models define the data elements used by clinicians in various
disciplines and their relationships. The models need to acurately
reflect the processes of clinical care and the culture of clinicians.
The development of a data model is a critical step in developing
data definitions and structures for electronic health records.
The
Australian Government has recently called for tenders for the
development of a general practice data model as part of the
development of standards for accreditation of general practice EHRs.
Larry Weed's work on POMR has not lost its relivance but as Francois
says the world moves on and concepts change. Nick Booth commented at
the last WONCA Classification Committee meeting that classification
systems need to take into account the rapid developments in IT if
they are to remain relivant in the future.
I suggest that the next
meeting of WICC might progress these ideas and consider Francois'
suggestion of a workshop.
Graeme Miller
Answer from Gerard Freriks
Mon, 18 Jan 1999 12:18:00 +0100
Dear Francois,
As you probably know, during the discussions via E-mail on the topic of the Domain Termlist of CEN/TC251 several of the items you mention were discussed.
In my view there is a need for a new classification and (re-) definition of old and new terms.
A classification which describes , what I call, the Medical Narrative.
In the Medical Narrative there are Terms/Concepts/Labels/(Headers) wich physicians use to write down the medical story as it unfolds.
This Medical Narrative is different from Classifications like ICPC or SNOMED or ICD-x.
It is a world in it self, a context in its own right.
The SOAP is a very crude, coarse grained classification. It served its purpose.
We need a new one.
But the use in not within GP systems only.
It will have repercussions on Hospital systems as well.
I suggest to wide the scope and try to include specialistic medicine also.
(via CEN/TC251, ISO/TC215, HL7-KONA)
I certainly have idea's for this revised one.
A workshop?
Fine, count me in.
An E-mail discussion?
So much better, faster.
Lets start
Gerard
Answer from Nick Booth
Mon, 18 Jan 1999 12:17:39 -0000
I would agre- it is time this is carefully reassessed from the point of view of family doctors and primary care. With increasing patient involvement in decision making it is also unclear as to what subjective and objective really mean.
Uncertainty when these concepts are being transferred across into Electronic Patient Health care record structure leads to contextual difficulty between communicating systems, and interferes with teamworking
Nick
Answer from Marc Jamoulle
Discussion about SOAP includes discussion about problem list and information structure but could not hide a more philosophical approach on the aim of health care delivery and patient doctor relationship.
Some texts for preparing this discussion :
For WEED the patient is always at the center of the process:
Citation from Weed's book : "Medical records, medical education, and patient care", 1969 p. 50;
"SUBJECTIVE DATA :this elements includes all the subjective information, including symptomatic data, and is always placed first to ensure that the patient's point of view will be taken in consideration at the outset [...]
OBJECTIVE DATA : In the objective data section of the progress note, doctors are frequently inclined to omit valuable physical findings that should be included. [...]"An about medical "art"
The true "art" lies in the imaginative interpretation of an action upon multiple variables that are consistently defined and accurately analyzed and transmitted." (p117)Thirty years later McWhinney writes in A Textbook of Family Medicine, 1997, p 379;
"The POMR made a stepforward by shifting the focus from disease to problems. But they are still aspect of care that are underrepresented. We have not yet found a way of recording the patient's experience of illness, expectation of care, resources, functional capacities, or feelings. The record is still "doctor-centered". [...]
Marc Jamoulle
Answer from Kumara Mendis
Re: SOAP why not HOPE?
Thu, 21 Jan 1999 23:41:51 +0500
At 10:27 PM 1/17/99 +0100, you wrote:
Back in 1968, Lawrence Weed published the princeps paper for :
1. The POMR
2. The SOAP descriptive pattern.
The SOAP pattern has been extensively used since then, in many environments.
However a growing concern is perceptible about its validity, especially
among the ICPC afficionados.
The concerns focuses on:
S- subjective, brings the notion of "all in the mind"
where as
O- Objective implies physicians findings; Often biased and anything but
Objective
So why not make it HOPE?
(as Donnely 1992: Arch Intern Med, 152, 481-4)
H - History (narrative account of the patient and the doctor)
O - Observations (for subjective + objective together)
A - Assessment
P - plan
O may be equal to Reason for Encounter
(RFE - patients reasons for contracting the health care system as clarified
and agreed with the primary care provider)
But the problem is using ICPC-2 to fit this?
O and A can be Coded.
H and P - ?
Kumara Mendis
Answer from marc jamoulle
feb, 1 1999
This paper describes some of the limitations of the POMR and discusses a
number of areas into which it could be extended.
http://www.ncl.ac.uk/~nphcare/PHCSG/conference/camb96/mikey.htm
marc J
