EVOLVING SOAP TO SUIT EVOLVING HEALTH CARE

Kannan Subramaniam*, Ashith R., Bharath R., Chandra Prakash R., Anandhasayanam A., Sangameswaran B.

Aim & Objectives: A subjective, Objective Assessment and Plan (SOAP) note has a major significance in healthcare, but there is no set format for documentation. This study systematically analyses current SOAP documentation practices followed by clinical pharmacy interns in a south Indian hospital. The SOAP formats/forms in use were reviewed, the gaps were observed and changes were suggested. Methods: A prospective Observational study was conducted in Multispecialty Hospital from June to September 2024 . A specialized data collection form was formulated and SOAP forms used in the Pulmonology, Cardiology, Neurology and Nephrology departments were reviewed and compared with any specific patient needs unfulfilled or gaps prevailing if any that could impact patient care outcomes were noted down. The forms were updated with department specific needs & the gaps were bridged. New SOAP note formats were formulated and compared with the old ones. The clinicians in charge of the departments reviewed the same and ethical committee clearance obtained for use. Results: In the existing SOAP form, in Subjective data, BMI was Missing in 100% of the Cases, Height/Weight in 60%, Lifestyle Data in 10%, and Symptoms in 40%, Duration of the illness in 80%, Family History in 20%, and Allergies in 46%, Medication History in 34%, and Symptoms in 18% of cases. Under Objective Data details missing were Cardiac Auscultation data in 20%, Blood Gas in 66%, SPO2 in 64%, CBC in 20%, RR in 100%, CBC in 16%, EEG in 100%, Fluid Status in 60%, Abdominal Examination in 50%, Urea Level in 20%. More details on the non pharmacological therapy and followup details were added to the plan section as they were missing in the old SOAP form. Conclusion: Even if the professional misses a point, the format or the form should remind him of the needs/essential data in a particular department. There are department specific needs that are to be addressed in detail. Customisation to every individual patient needs is the right approach and that has to start from department specific needs and a 360 degree approach to cover all details major or minor. Gaps were there in the form or format as well as in filling and collecting detailed information that were vital and the new forms proved to be more informative for the healthcare team compared to the old ones and a comparative study in more patients can prove this observation statistically.