Larry Weed and SOAP notes


Category : Medical Rants

1973, as we prepare to start our clinical rotations, the chief medical residents taught us the new concept of SOAP notes.  Larry Weed developed the concepts of the problem oriented medical record and notes that included subjective, objective, assessment and plans for each problem.  We wrote our notes each day using his system.

I have wondered in many conversations what he would think of the unreadable computer printout notes of 2017.  We wrote notes on each problem with a careful assessment and plan.  We had no concern for doing a complete review of systems and physical exam each day, rather we focused on the patient’s problems, including subjective complaints, abnormal physical findings, abnormal laboratory tests and images.  Each day we reviewed our problem list, sometimes resolving a problem, sometimes adding new problems.

I remember several patients during my internship that I am certain benefited from my careful listing of problems and thoughtful assessments and plans.  Our subjective (history taking) and objective (physical exam, labs tests, etc) remarks were attached to a problem.  For example, in a patient admitted with known systolic dysfunction, The problem (heart failure with systolic dysfunction) would include in the subjective comments on dyspnea, ankle swelling, chest pain, while the physical exam would include looking at the jugular veins, describing the heart and lung exams and mentioning the presence or absence of ankle edema.  It would likely also include the current medication list, EKG, chest X-ray, echocardiogram, previous cardiac procedures, etc.  The assessment would describe our interpretation of the current status of his heart disease and volume status.  The plan would describe medication changes, test orders, need for a consult.

While not every note addressed the problems completely, generally the notes contained much information than our current notes.  We understood the genius of Larry Weed’s change in our patient notes.

I have wondered how he would interpret the degradation of his ideas.  We can blame the electronic medical record.  We can blame CMS and their arcane billing requirements.  Patient care suffers in my opinion.  Larry Weed helped us work on the thought process.  We need to once again reinvent the note to value the thought process and the careful recording of our thoughts.

Rest in peace, Larry Weed.  I never met you or saw you in person, but I had great respect for you throughout my medical career.

Comments (7)

I did meet Larry Weed a couple of times.
I didn’t always agree with him, but there is no question he was a brilliant, committed doc. He changed two generations of medicine.
There is some suggestion in his NY Times obit the way EMRs have gone disappointed him. Very understandable.
This might be your best post ever, Dr. C.

thanks – high praise from someone who really understands internal medicine – I am honored

I wonder if Weed went a little off the rails in his later writings with his ideas about “knowledge couplers” , computer applications which he thought should someday replace clinical judgment.

On the other hand I love his original ideas. One of his first principles was “state the patient’s problem only at the level of resolution you have at the time.” If all you can say is that the patient’s EKG looks funny then put “funny EKG” in the problem list, he once said. In contrast to what coders and administrators tell us today, he thought symptom statements as problems were OK, at least initially, until further data or expertise could be applied. This would help avoid being too specific too early, which sometimes leads to diagnostic error.

I didn’t agree with everything he had to say but he was a real visionary.

excellent comment – I agree with everything you have written

“We can blame the electronic medical record.  We can blame CMS and their arcane billing requirements.”

If we’re playing the blame game, we need to start with blaming ourselves and our professional societies who enthusiastically participated in making this happen.

(Still on paper and loving my SOAP notes)

Obviously we did not think through the unintended consequences of EMRs.

So wistful! Gone are the days of the SOAP notes. 🙁
When I learned about them in medical school I then religiously employed that format throughout my residency and until the EMR destroyed such an approach. However, I still teach the trainees and set my expectations for their notes to contain a very clear problem list oriented set of A/Ps, which of course should be based upon the preceding S and O. So I think we can still use Dr. Weed’s groundbreaking approach for approaching the patient.

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