What’s the difference between a H & P note and a SOAP note?
The difference between H & P and SOAP notes lies in their structure and how they organise clinical information.
H & P, which stands for History of Presenting Complaint, is a format that first details the patient's current complaint in a chronological manner and then sequentially documents their medical history, examination findings, impression/diagnosis, and management plan.
This approach is commonly used in Australia and provides a comprehensive view of the patient's condition from onset to treatment.
SOAP, which is an acronym for Subjective, Objective, Assessment, and Plan, is the note style widely utilised in the US and other regions. This format segregates the clinical information into four distinct sections: the patient's subjective description of their problem, objective data from physical examination and tests, the healthcare provider's assessment or diagnosis of the condition, and the proposed plan for managing the patient's care. SOAP notes are favoured for their clear, organised approach to documenting patient care across various healthcare disciplines.
What’s the difference between SOAP and SOAP (issues)?
The distinction between SOAP and SOAP (Issues) notes lies in their approach to documenting and managing multiple patient concerns. The classic SOAP format is ideally suited for addressing a single, specific concern or symptom a patient presents with. It follows a straightforward structure, guiding the clinician.
On the other hand, SOAP (Issues) incorporates a Problem List or Issues List into the Assessment and Plan sections, making it more effective for managing patients who present with multiple requests or problems. This modified approach allows for each issue to be assessed and addressed separately within the same document, ensuring a more organised and comprehensive plan for patients with complex or multiple healthcare needs. SOAP (Issues) is particularly useful in scenarios where patients have a variety of concerns that require distinct evaluations and management plans.
Other options than SOAP or H & P?
Beyond SOAP and H & P formats, Heidi offers further customisation for clinical documentation through the template section located on the right side of your screen.
While SOAP and H & P are foundational for creating the initial consult summary displayed on the left panel, the template section on the right allows for the use of preset templates or the creation of custom ones.
These customisable templates enable you to structure the clinical note in a way that best fits your clinical approach, providing the flexibility to address diverse clinical scenarios. Moreover, this feature is not limited to clinical notes; it also facilitates the creation of additional documents such as referral letters and medical certificates. For guidance on setting up and utilising these templates, please refer to our short tutorial available at this link.
Specialty Note
Heidi offers profession & specialty-specific formats for your clinical notes, such as ADIME for dieticians and IMIST-AMBO for paramedics. Make sure you have selected your right specialty in your settings!