A return to the problem-oriented SOAP note

CMS is changing note requirements, among other changes.  Bob Doherty has a wonderful summary: “Medicare’s historic proposal to change how it pays physicians.”

As always, we really will have a difficult time sorting out the unintended consequences of these changes, but they certainly seem like a move in the proper direction.  To me the most important change is a focus on notes: “Allowing medical decision making to be the basis for documentation, requiring physicians to only document changed information for established patients and to sign-off on basic information documented by practice staff.”

Hopefully, we will begin to teach and expect Larry Weed’s SOAP notes as taught in the early 70s.  Here is an example of a totally fictional hospital note that I might have written in 1975.

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