Healthy Choices

Can you tell the difference between gobbledygook and your medical record?

If you think your doctor’s penmanship is atrocious, it probably is. There’s a reason for that: So her signature cannot easily be copied.

If you think reading your medical record will be easier than recognizing your doctor’s signature, think again.

Medical schools teach a method of note-taking that, for better or worse, looks like a secret code for medical professionals. It’s a tough one to crack if you want to read your medical records.

The acronym SOAP explains the structure of medical records. It stands for Subjective, Objective, Assessment, Plan.

The “subjective” is a narrative of your symptoms, or your chief complaint. The “objective” describes the findings your doctor made during an exam, including vital signs. The “assessment” lists the thinking of your doctor about your diagnosis, and “plan” is where the doctor describes her recommendations.

It’s all done in shorthand that might look like this:

43 y/o ♀ w/RUQ pain, occ. rad. midepigastr., esp. ρ fatty foods; acute onset x 1 mo., wkly x 30', incr. freq. X 1 wk. θf/c/n/v/d. S/P appy, hx HTN rx'd w/HCTZ-25 mg, 1 po q.d. E: VSS/NI, afeb, θHSM, + pain w/palp. RUQ, θrebound Imp: ?gallstone, r/o PUD, hepatitis P: √ US, LFTs, CBC, avoid FFs, call if Sx worse/f/n/v, ph. f/u 2-3d, appt. 3wks.

Which translates to:

The patient is a 43-year-old woman with abdominal pain in the right-upper abdomen, occasionally radiating to the mid upper abdomen, especially after eating fatty foods. It started rather abruptly about one month ago, occurring weekly, lasting 30 minutes, but it has become more frequent over the last week. There has been no associated fever, chills, nausea, vomiting or diarrhea; she has had an appendectomy, and has a history of hypertension treated with hydrochlorothiazide, 25 milligrams, one by mouth daily. On physical examination, vital signs are stable and normal; she does not have fever. Examination of the abdomen reveals normal size liver and spleen, but there is pain with pressure in right upper abdomen without pain when the pressure is quickly released. Impression: possible gallstone but cannot rule out peptic ulcer disease or hepatitis. Plan: check ultrasound, liver-function tests, complete blood count. Avoid fatty foods. Patient to call if symptoms worsen, or if fever, nausea, or vomiting develops. She will follow-up in two or three days by phone and the next appointment will be scheduled for three weeks.