SOAP to SNOCAMP: improving the medical record format.
Not since the development of the SOAP note in the problem-oriented medical record has there been a significant need to alter the format of medical record documentation. With the intrusion of third-party audits, malpractice attorney subpoenas, medical guidelines, and reimbursement code criteria into the practice of medicine, there is a need to expand the traditional SOAP note. This article proposes a new acronym, "SNOCAMP," for medical record documentation. SNOCAMP retains the SOAP format, which includes subjective, objective, assessment, and plan of treatment, with the addition of nature of the presenting complaint, counseling, and medical decision-making. It is hoped that this new, more explicit format will prove successful in meeting the divergent needs of practicing physicians, the patients they serve, and the inquiring minds that look over their shoulders.
Larimore
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St. Anthony's Publishing, Reston, Virginia, USA.
Jordan
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D003933:Diagnosis; D004282:Documentation / Q000379:methods*; D006801:Humans; D009819:Office Visits; D010347:Patient Care Planning; D011996:Records; D014481:United States