DAILY FOLLOW UP NOTES’ ACCURACY ACCORDING TO SOAP (SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN) FORMAT

Abstract

A Objective: To assess the accuracy of daily follow up notes in accordance with SOAP (subjective, objective, assessment, plan) format and determine the awareness of standard guidelines among the house officers and post-graduates at Ziauddin Hospital. Methods: A cross-sectional study conducted over a one month period. A total 460 follow up notes documented by house officers and postgraduate trainees from four departments were assessed via a preformed checklist based on the SOAP format. In addition, house officers and post graduate trainees were assessed regarding their awareness of SOAP format. Results: The most common component addressed (n=420, 91.3%) was the active complaint of the patient and variable least addressed was imaging studies (n=21, 4.6%). The second part of the study demonstrated that 87% (n=20) of the doctors knew about the exact components of the SOAP format. This format was used by 78.3% (n=18) participants to put daily follow-up notes. The 21.7% (n=5) who do not put follow-up notes according to the SOAP format: 20% (n=5) believe it is of no use, 40% (n=9) find it time-consuming and 40% (n=9) do not do so because no one asks them to follow the SOAP format. Conclusion: Level of accuracy of daily follow up notes on the basis of SOAP format at our hospital was not up to the mark. Awareness of the house officers and postgraduate trainees regarding the SOAP format was adequate; however there is a need to emphasize the importance of SOAP for every new batch of house officers and postgraduates. Key words: Documentation (MeSH), awareness (MeSH), SOAP format (Non-MeSH), daily follow-up notes (Non-MeSH)