by Dava Stewart
Although we know S.O.A.P. notes can improve patient outcomes, the actual process of taking those notes may be uncomfortable for your patients. There was an entire Seinfeld episode based on the fact that people feel odd when doctors take notes during an exam. How can DCs be thorough note takers without making patients feel uncomfortable? The key to taking good notes while helping patients remain at ease is good communication.
Holding a clipboard and jotting things down may have been less distracting than entering notes into a computer. However, with the rise of electronic health record (EHR) systems, taking notes on a screen makes the process simpler than it would be using paper. Talk to your patient about what you are doing, so that they don’t feel you are ignoring them. If possible, make sure they can see the screen.
Going beyond simple note taking can be useful, as well. If you can describe a patient’s condition more clearly using a diagram, or if you can show the patient progress over time with a chart, the role of the screen changes. It stops being a distraction and becomes a point of interaction that improves the patient’s understanding.
Depending on your EHR system and the equipment you use, a tablet may be the least intrusive method of computerized note taking. Most have detachable keyboards so that they are easily portable. The fact that tablets are smaller and more similar to a clipboard may make them seem less daunting to patients.
There is some evidence that patients don’t mind practitioners taking notes on a computer during an exam. In fact, as the use of EHRs rise throughout the healthcare industry, patients probably expect caregivers to take notes. It may well be that DCs (and other healthcare providers) are more uncomfortable with the technology that surrounds electronic note taking than patients are.
Of course there are ways to work around taking electronic notes during an exam: using audio, having a person present to take notes during the consultation, or using a transcription service. It’s likely that a recorder or a third-party note taker would be easier for the practitioner, but it could be far more uncomfortable for patient. As for transcription, a study published in the Journal of the American Health Informatics Association in May 2010 concluded that it is possible a lower quality of care is delivered than if the caregiver directly takes notes.
One simple way to make sure your patients are comfortable with note taking is to ask them. Explain what you are writing and why and find out how they feel about it. Their answers may surprise you.
