A way forward: SOAP notes are imperative for healthcare professionals

The headline of our community paper stated a fact that people in every province and territory already know.  “Doctor Shortage Reaching a Critical Point”  (Comox Valley Record – July 21, 2021)

No doubt, our hospitals and public health offices performed admirably under the stresses of Covid19, but there are cracks in the system big enough to hold the hundreds of thousands of Canadians without a doctor.

People here react to this “news” of a shortage of primary caregivers with fear and dread. They’re left hanging, abandoned by the system, worried they won’t get the services they need. As a part of the healthcare community excluded from the national monopoly that exists, I reacted to the headline and the article with exasperation.  Once again feeling slighted. I am tired of being marginalized by the healthcare system, brushed aside and frozen out. I am frustrated that my skills in primary care are overlooked, under-appreciated and under-utilized.

The local physician interviewed for the piece euphemistically described the problem as “an acute attachment gap.” Public discourse is rich in trite, predictable terms.

The B.C. Ministry of Health acknowledged the situation, saying it is looking into the problem. “Because people come and go, the plan for the community will need to adjust over time as the community need evolves. The Ministry is collaborating with the local Primary Care Network to look at local strategies to ensure patients can receive primary care when they need it – including adding new family physicians and nurse practitioner resources.”

The PCN was an initiative launched in September 2020 to partner local healthcare professionals with new Indigenous resources and community organizations as part of a networked, team-based approach to providing integrated, whole-person care. “We are requesting funds to be able to attract and hire those care providers.” More money, please!

“Rarely a year goes by that there is not some big-budget, high-profile federal or provincial commission of inquiry into health care and, most notably, health budgets. Political cliches fill the air about efficiencies, more billions of dollars, wait-lists  and the availability of qualified professionals. Nothing ever changes in a substantive way, except the public perception that Canada’s health care system has gone steadily downhill for a quarter century.”

This quote, fresh and relevant as it is, was written in 2005: “Squandering Billions: Health Care in Canada” (Bannerman and Nixdorf – Hancock House)   It is both informative and provocative, cutting to the heart of what really ails our system. We have independent, for-profit businesses granted a monopoly within a socialized framework – the public picks up the tab, few questions asked.  

“The merchant doctor faces no competition and the consumer-patient has a blank cheque for unlimited shopping.”

But the shelf at the government-run store is prone to bareness.  

The healthcare marketplace in Canada has become distorted and twisted up in complicated ways, and now it is rather unhealthy.  Bureaucracies flourish, patients languish, and qualified professionals are sidelined. I think it is time for some changes – real changes – to our current system. But honestly, I’ve been waiting for that to happen since the year I started my Chiropractic education, the year the Canada Health Act came into effect,  and that year was 1984.  So, don’t hold your breath! Rather than perpetually stewing in a sense of frustration over the unfairness of the system, we need to step up to the plate and, as Ghandi counselled: “Be the change you want to see in the world.” The pandemic has given us a tremendous opportunity to do just that.   

In this new era of tele-health and video conferencing, family doctors have become much less reliant on the physical examination. There are fewer and fewer hands-on encounters and that’s where we come in. There is no substitute for the actual experience of conducting a competent physical exam, and that’s as true for patients as it is for their healthcare professional. The most effective physical examination is guided by the patient’s history of the complaint and a structured approach to documenting the findings. This means you have a ‘form’ – be it paper or digital – which is custom-made for you. Set up your form to reflect how you systematically approach the exam process.

It can be organized by region – anatomic or functional. Or by the sequence you use – standing, sitting, prone and then supine. Or by the general categories which must be included as essential elements of all physical examinations. Remember, when using the SOAP-note method, document physical examination findings under the heading of O – Objective. Objective tests are observable, measurable, reproducible, reliable (both intra and inter-examiner), sensitive and specific to the parameters you want to measure.

The Complete Physical Examination

 Observations

• Note the symmetry of form and motion, the power and rhythm of their gait, the tone of their posture.
• Inspect the skin for abnormalities of pigmentation and texture and integrity.

Palpation

• Visualize the anatomy under your hands, appreciate the contours and size and condition of the tissues.
• Evaluate temperature and turgor and tender points.

Range of Motion

• Screen for restrictions in active range of motion of a joint.  If they are full and pain-free in all possible planes, then you’re done.  Any limitations require a closer look.
• Passively assess the integrity of non-contractile elements and the quality of joint play.

Neurological

• Resisted action (muscle testing) is performed at the midway point of a joint’s range.
• Testing reflexes (cutaneous and deep tendon) and evaluating the distribution of sensory changes are helpful tools for pinpointing pathologies.

Special Tests

• Challenging specific tissues is a logical way to differentiate various orthopedic and neurovascular problems. Over the years many tests have been devised by people who’s name is now attached. There are several online resources for reference.

Vitals

• Heart rate, breathing rate, blood pressure, body temperature, height/weight/BMI,  auscultation of heart sounds, lung fields and abdominal quadrants,  percussion of chest/abdomen.

All of these parameters of a patient’s physical condition are readily assessed if you have the right tools on hand – a sphygmomanometer and stethoscope, a thermometer, a timer and weight/height scale.  Throw in a reflex hammer, a pointy pinwheel and a goniometer and you are good to go.

Recording the findings of a physical examination is facilitated by that consciously constructed form you employ.   Paper or electronic records can consist of text entries, drawing on body diagrams, checklists, grading scales (numeric or mild/moderate/severe), +/-/within normal limits entries and, last but not least, the highly efficient Maigne diagram for charting ROM’s.

If you don’t already do it, consider performing physical examinations with a ‘thinking out loud’ approach.  It is a good habit to let your patients know what you’re looking for and what you’re finding.

Be sure to encourage their questions and listen carefully for clues to their unique situation. And don’t forget that primary care physicians are not expected to successfully treat every condition which presents.  The point of primary care is to figure out what’s next.  Patients want to know what’s going on, should they be worried, what can they expect, what can be done and can you help them?

We have the training to discern the functional from the pathological.We can inform and reassure and make recommendations on further investigations or the best path to resolution of their troubles. So be the best you can be at those physical examinations.Use your talented hands, educated brain and curious, caring heart to everyone’s advantage. No health profession has a monopoly on these things.

References

1. Squandering Billions: Health Care in Canada   (Bannerman & Nixdorf  Hancock House 2005)
2. Physical Examination of the Spine and Extremities  (Hoppenfeld  Appleton-Century-Crofts 1976)
3. Clinical Record Keeping: A Hands-On Approach  (Armstrong, D. – Online Course – see details at  auroraeducationservices.ca

DR. DAWN ARMSTRONG is a graduate of CMCC and has been in practice for over 30 years. She is currently focused on promoting life-long learning and professional development and has created a continuing education course – Clinical Record Keeping: A Hands-On Approach. Learn more at auroraeducationservices.ca.