Lawrence Weed MD1, was responsible for introducing the SOAP system of record keeping in 1968. Since then it has become standard practice in health care record keeping in America, but not so much in South Africa. Before investigating the merits of the SOAP system, one must reflect on what the guidelines of record keeping by the HPCSA, stipulate.
The first thing that comes to mind when considering record keeping is the Doctor/Patient confidentiality. Yes, important, but there is a lot more to it than just that. The HPCSA presents the following ethical guidelines to guide and direct the practice of health care practitioners. These guidelines form an integral part of the standards of professional conduct against which a complaint of professional misconduct will be evaluated.*
Definition of a health record *
A health record may be defined as any relevant record made by a health care practitioner at the time of or subsequent to a consultation and / or examination or the application of health management.
A health record contains the information about the health of an identifiable individual recorded by a health care professional, either personally or at his or her direction.
Checklist for health record-keeping*
Good notes imply good practice and the following checklist may serve to guide health care practitioners in the appropriate keeping of patient records:
- Records should be complete, but concise.
- Records should be consistent.
- Self-serving or disapproving comments should be avoided in patient records. Unsolicited comments should be avoided (i.e. the facts should be described, and conclusions only essential for patient care made).
- A standardised format should be used (e.g. notes should contain in order: the history, physical findings, investigations, diagnosis, treatment and outcome.).
- If the record needs alteration in the interests of patient care, a line in ink should be put through the original entry so that it remains legible; the alterations should be signed in full and dated; and, when possible, a new note should refer to the correction without altering the initial entry.
- Copies of records should only be released after receiving proper authorisation.
- Billing records should be kept separate from patient care records.
- Attached documents such as diagrams, laboratory results, photographs, charts, etc. should always be labelled. Sheets of paper should not be identified simply by being bound or stapled together – each individual sheet should be labelled.
Why records should be retained*
Documents and materials should be retained in order to:
- Further the diagnosis or ongoing clinical management of the patient;
- Conduct clinical audits;
- Promote teaching and research;
- Be used for administrative or other purposes;
- Be kept as direct evidence in litigation or for occupational disease or injury compensation purposes;
- Be used as research data;
- Be kept for historical purposes;
- Promote good clinical and laboratory practices;
- Make case reviews possible;
- Serve as the basis for accreditation.
Alteration of records *
No information or entry may be removed from a health record.
An error or incorrect entry discovered in the record may be corrected by placing a line through it with ink and correcting it. The date of change must be entered and the correction must be signed in full. The original record must remain intact and fully legible. Additional entries added at a later date must be dated and signed in full. The reason for an amendment or error should also be specified on the record.
Duration for keeping records*
Health records should be stored for a period of not less than six years as from the date they became dormant. In the case of minors and those patients who are mentally incompetent, health care practitioners should keep the records for a longer period: For minors under the age of 18 year’s health records should be kept until the minor’s 21st birthday because legally minors have up to three years after they reach the age of 18 years to bring a claim. For mentally incompetent patients the records should be kept for the duration of the patient’s lifetime.
Ownership of records*
A complaint that far too often arises in optometry, is the refusal of an optometrist to release a patient RX to a colleague. The patient is entitled to the prescription.
In cases where patients are required to pay for records and images (e.g. private patients or patients in private hospitals) such patients must be allowed to retain such records – unless the health care practitioners deem it necessary to retain such records for purpose of monitoring treatment for a given period. Should the patient however require the records and / or images to further or protect an interest (e.g. such as consulting with another practitioner) he or she must be allowed to obtain the originals for these purposes.
Should a health care practitioner in private practice (both in a single practice and in a partnership) pass away, his or her estate, which includes the records, will be administered by the executor of the estate:
Should a practice be taken over by another health care practitioner, the executor shall carry over the records to the new health care professional. The new health care practitioner is obliged to take reasonable steps to inform all patients regarding the change in ownership and that the patient could remain with the new health care practitioner or could request that his or her records be transferred to another health care practitioner of his or her choice.
After the date concerned, the records will be kept in safe-keeping for a period of at least twelve months by an identified health care practitioner or health institution with full authority to deal with the files as he or she may deem appropriate, provided the provisions of the rules on professional confidentiality are observed
Access to Records*
In terms of the law, the following principles apply in regard to access to information in health records: A health care practitioner shall provide any person of age 12 years and older with a copy or abstract or direct access to his or her own records regarding medical treatment on request (Children’s Act (Act No. 38 of 2005). Where the patient is under the age of 16 years, the parent or legal guardian may make the application for access to the records, but such access should only be given on receipt of written authorization by the patient (Access to Information Act (Act No. 2 of 2000).
No health care practitioner shall make information available to any third party without the written authorisation of the patient or a court order or where non-disclosure of the information would represent a serious threat to public health (National Health Act (Act 61 of 2003)).
A health care practitioner may make available the records to a third party without the written authorisation of the patient or his or her legal representative under the following circumstances:
Where a court orders the records to be handed to the third party; Where the third party is a health care practitioner who is being sued by a patient and needs access to the records to mount a defense.
Where the third party is a health care practitioner who has had disciplinary proceedings instituted against him or her by the HPCSA and requires access to the records to defend himself or herself.
Where the health care practitioner is under a statutory obligation to disclose certain medical facts, (e.g. reporting a case of suspected child abuse in terms of the Children’s Act, (Act No. 38 of 2005)).
Where the non-disclosure of the medical information about the patient would represent a serious threat to public health (National Health Act (Act No. 61 of 2003)).
In provincial hospitals medical records must be kept under the care and control of the clinical manager. Access to such records shall be subject to compliance with the requirements of the Access to Information Act and such conditions as may be approved by the superintendent.
Retention of patient records on CD-Rom*
Storage of clinical records on computer compact disc (CD-ROM) is permissible, provided that protective measures are in place:
- Only CD-ROM technology that is designed to record a CD once only, so that old information cannot be overwritten, but new information can be added is used;
- All clinical records stored on computer compact disc and copies thereof are to be encrypted and protected by a password in order to prevent unauthorised persons to have access to such information;
- A copy of the CD-ROM to be used in the practitioner’s rooms will be in a read-only format;
- A back-up copy of the CD-ROM must be kept and stored in a physically different site in order that the two discs can be compared in the case of any suspicion of tampering;
- Effective safeguards against unauthorised use or retransmission of confidential patient information must be assured before such information was entered on the computer disc. The right of patients to privacy, security and confidentiality must be protected at all times.
Nothing can be more frustrating in a clinical setting, than not being able to make head or tail of the clinical notes on a follow up patient visit. Using one liners or cryptic notes can become confusing even when it is your own work. The SOAP system has the makings of standardising record keeping among colleagues and even across locations. Long term relationships with patients is the cornerstone of good optometric practice. To maintain and protect this relationship, the patient history is a very valuable component to the patient and optometrists alike. It is well worthwhile to make every effort that good record keeping will ensure good clinical delivery down the line.
Effective record notes must reflect the following four criteria:
- The patient’s record must reflect subjective comments that are consistent with a visual problem or condition.
- The examination must confirm the existence of a condition that isconsistent with the patient’s complaints and the examination findings must be documented.
- The management of the case or treatment rendered must be considered appropriate for the condition.
- The patient chart should reflect overall improvement with time both subjectively and by clinical examination findings.
How SOAP works
It is common practice that a Master File will be opened for every patient. This will contain the obvious name, address, phone number, but also a unique identification such a Date of Birth or ID number.
The patient examination must be recorded under the four headings: Subjective, Objective, Assessment and Plan2.
S = Subjective reflects the chief complaint and case history of the patient. Using the patient’s own words; what is the reason for the visit. Routine use of one‐word entries or short phrases such as “better”, “same”, “worse”, “headache”, “back pain” is not good practice.
- Onset (when and mechanism of injury – if applicable)
- Chronology (better or worse since onset, episodic, variable, constant, etc.)
- Quality (sharp, dull, etc.)
- Severity (usually a pain rating)
- Modifying factors (what aggravates/reduces the complaint – activities, postures, drugs, etc.)
- Additional symptoms (un/related or significant symptoms to the chief complaint)
- Treatment (has the patient seen another provider for this symptom?)
O = Objective
This is what the clinician finds – the outcomes from the examination. It is the documentationof objective, repeatable, and traceable facts about the patient’s status.
- External anterior ocular assessment.
- Binocular vision assessment
- Fundus examination
- Slit lamp examination
- Refraction, and so on.
A = Assessment
This is the optometrist’s diagnosis. This is the diagnostic impression or working diagnosis and is based onthe “S” and “O” components of SOAP. On follow‐up visits the “A” should reflect changes in “S”and “O” as a response to time, treatment, and other interim events.
“A” should be continually updated to be anaccurate portrayal of the patient’s present condition.
P = Plan
This describes what the health care provider will do to treat the patient – prescribing spectacles, contact lens trial, referrals,expected outcomes and goals of treatment.
Clinicians would do well to heed the jurisprudence with respect to record keeping; “If you didn’t write it down, you didn’t do it”. Poor record keeping can have serious legal implications and threaten a professional career when the clinician has a good case against a law suit, but not the hard evidence. Apart from that, good record keeping sets the stage for good clinical delivery and points to long term patient relationships and goodwill. The SOAP system provides a consistent approach to health care record keeping and has withstood the test of time.
- Weed L. Medical records that guide and teach. NEJM Vol. 278, No. 11 & 12. 1968.
- * HPCSA website – Guide lines on the keeping of patient records http://www.hpcsa.co.za/Uploads/editor/UserFiles/download
- The best practice in clinical record keeping: SOAP notes – hpgroup.com/images/Documents/helper%20packet/BestPracticesSOAP.pdfs/conduct_ethics/Booklet%209.pdf
- EMRSoap – https://www.emrsoap.com/about-us/