Redefine Your Patient Encounter
Like all doctors, I was trained to frame and report every patient encounter using the SOAP note. SOAP stands for the Subjective-Objective-Assessment and Plan method. It is a disease-based approach that sets the tone for all that goes on in health care. The priority is to identify the disease, measure it to confirm what it is (based on standard categories), and develop a treatment plan to try to control and eliminate it.
This approach works best when there is a clear cause of a disease that is easily identified and eliminated. However, it works poorly when a disease is chronic and multifactorial. As an added challenge, most of these factors that are now seen to impact most of health promotion—social and environmental factors, lifestyle and self-healing practices – are factors that largely lie outside of most medical encounters.
These factors are what create 80 percent of health.
They live outside of the clinic, and don’t easily fit into the diagnostic-treatment plan that we create with SOAP. For example, the SOAP often excludes social and emotional factors, a patient’s goals and what matters most to them. It often does not make room for shared decision-making with a patient. These items are crucial for the creation of health and healing, sometimes even more so than the treatments I provide for the disease.
As a primary care provider, I’ve found that the SOAP note is too narrow to effectively grasp the causes of and approaches needed for many of the conditions I see – conditions like chronic pain, obesity, diabetes and hypertension.
We can do better for ourselves and our patients if we go beyond the SOAP note.
Adding HOPE to Health Care
By the time patients see me, they often say they have “tried everything” and this was certainly true of a patient of mine who heard I had a different approach that might help her.
What began as a minor car accident turned into 15 years of chronic pain in her neck, PTSD and crying spells. She tried medications, physical therapy, steroid injections, electrical stimulators and psychotherapy in addition to complementary and alternative practices like chiropractic care, acupuncture, herbal medicine, mind-body practices and more. Temporarily, each provided relief, but on most days she still rated her pain at a five to seven out of ten despite being on several prescription pain killers.
For patients like this, a simple SOAP note doesn’t get to the root of the problem, nor the solution. You need to add another dimension for healing to occur—that element is what I call the HOPE Note.
Here’s how it works.
From SOAP to HOPE
Once you have completed the traditional SOAP note, go a step further and set up a visit to ask a few other questions.
By adding these questions to the patient encounter, you can simply, but radically, shift the care focus to core healing factors by empowering our patients and engaging them on their own path to healing.
Document this with the HOPE note. This taps into the 80% of health that occurs outside the medical system. The basic HOPE questions are the following:
MENTAL AND SPIRITUAL AREAS
1. What is your goal for your healing? What do you want to heal?
- Are you hoping to achieve a certain percentage less pain or improve function, for example regain the ability to climb stairs or play with a grandchild?
- Rate your health and what you expect can happen (1-10)
- Why are you here in life? What is meaningful for you? What is your purpose?
This addresses a person’s the inner life — their desires, their beliefs, and their needs—why they get up in the morning, their purpose in life—what’s meaningful for them? What gives them a sense of wellbeing and motivation? What matter rather than what is the matter.
Sometimes a simple thing such as spending time in the woods, or with family, is the primary avenue into treating their pain. Sometimes the goal of being able to play with their grandchildren will generate the physical activity necessary to prevent a future illness or disease that could impair them. Sometimes it’s the desire to serve their country, or their God.
SOCIAL AND EMOTIONAL AREAS
2. What are your connections and relationships?
- Do you have family, friends, live alone, have hobbies, and have fun? Can you get rides to airport?
- Tell me about yourself. Tell me about your traumas. Do you have a best friend? Are you part of a group? A club? How often do you meet?
So often the reason and process for healing has to do with social relationships — with family, friends, communities and colleagues. Therefore, after we finish putting lines around the box of the diagnosis and the treatment, let’s capture the social components and the interpersonal components that drive an individual in their daily life.
LIFESTYLE AND BEHAVIORAL AREAS
3. What do you do during the day?What is your lifestyle like?
- Do you smoke or drink? What about diet, exercise, sleep and water?
- What do you do for stress management? How do you relax, reflect and recreate?
- What is your CAM use (supplements, herbs, other practitioners)?
Lifestyle and behavior can impact up to 60-70 percent of chronic illnesses; therefore, these behaviors are essential for creating health. But behavior change must be connected to what is meaningful for the person, or it cannot be sustained.
4. What is your home like? Your work environment? Do you get out in nature?
- This includes light, noise, clutter, colors, plants, walls.
The communities, the work sites, the schools and the environment in which our patients live, often dictate what they’re able to do, what happens, how long they live, and how well flourish, and how well they function. The physical environment, then, needs to be explored.
Let’s make asking these questions a routine part of medical care.
In the Healing Oriented Practices and Environments (HOPE) model, the patient and their own goals are part of the diagnosis and the plan. Expectations and beliefs are a key part of healing, as are social support and relationships that are essential for recovery and optimization of any kind of treatment. Thus, the social, behavioral, environmental and spiritual components are part of the note.
These questions help us to engage patients in shared decision-making about their health and healing. They help encourage conversation about risk factors and reducing risk. Best of all they highlight the patient’s own intuition on what they need most to heal.
As providers, we can expand our knowledge culled from experience and rigorous research. Together, patient and provider can spark healing beyond the SOAP Note.
For my pain patient, we discovered that damage to her frontal lobe from a car accident had been preventing the treatments from being effective. Once we reestablished the proper neurological foundation, the treatments for her pain began to last. Treatment included traditional medicine including a low dose antidepressant and over the counter acetaminophen, acupuncture and self-care including sufficient sleep and stress management.
She began to see that when pain levels began rising, it was often because she had not engaged in sufficient self-care. She felt empowered, in control of her life, and best of all—had hope for the future.
Want more science? Read more directly from the source:
- Jonas WB, Rakel DA, Developing optimal healing environments in family medicine. In: Textbook of Family Medicine: Seventh Edition. Rakel R.E. Philadelphia PA. Saunders 2007; 15-24.
- Lehman R. Sharing as the Future of Medicine. JAMA Intern Med. Published online July 03, 2017. doi:10.1001/jamainternmed.2017.2371