Supporting patients’ understanding of likely outcomes and including them in decision-making can improve patient care and prevent malpractice allegations. An expansion of the commonly used SOAP (Subjective, Objective, Assessment, Plan) format helps to prompt and document these efforts. The SOOOAAP (Subjective, Objective, Opinion, Options, Advice, Agreed Plan) format stimulates communication, aligns expectations, and fortifies malpractice defenses. Here’s how it works:
• Subjective. This section contains the patient’s new or primary concern.
• Objective. This section provides a list of measurable, reproducible data, including laboratory or imaging findings.
• Opinion. This section replaces the “Assessment” section of the traditional SOAP note. It will prompt you to communicate the limitations of medical diagnosis to the patient. Your documentation in this section should avoid false certainties and provide evidence of your comprehensive care.
• Options. This section supplements the “Plan” section of SOAP. It will prompt you to improve information sharing with your patients, for example, by discussing risks, benefits, and alternatives. Provide evidence of informed consent or informed refusal, encourage patients to take responsibility for their choices, and document accordingly.
• Advice. This section distills options into the best choice and funnels your advice into a coherent statement with supportive reasoning. Document your reinforcement of the principle that the physician advises and the patient chooses. Confront unreasonable expectations, encourage health maintenance and wellness, and protect people who are not your patients through proxy advice (e.g., “Advised to notify sexual contacts”).
• Agreed Plan. This section synthesizes the physician's guidance and the patient's choice into a coherent statement that the patient understands and agrees to follow. Document goals or expected outcomes with time frames and record the patient’s responsibility to the plan and for follow-up (e.g., “Patient understands and agrees with plan,” “Patient agrees to schedule and keep follow-up appointment”).
See how this expanded format works in a sample SOOOAAP note.
Read the full FPM article: “Documentation Tips for Reducing Malpractice Risk.”
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