Artificial Intelligence and the Restoration of the Medical SOAP Note Part 2: Assessment Deconstructed
As I discussed in Part I of this series, the Assessment is the 3rd section in a SOAP note, and represents a tightly worded yet comprehensive summary of the patient's current situation. Below is an example of a typical Assessment statement:
Mrs. Singh is a 69 yo Indian female with HTN and poorly controlled diabetes admitted 7 days ago with an acute NSTEMI and cardiogenic shock, status-post left heart catheterization with PCI to LAD and circumflex. Course complicated by a right external iliac injury during placement of intra-aortic balloon pump, subsequently resolved with successful repair of the iliac artery. Patient transferred out of the ICU 2 days ago, is hemodynamically stable and beginning to ambulate.*
In this 74 word summary, the clinician elegantly provides a comprehensive narrative summary of what appears to be a complex and somewhat fraught 7 day hospitalization. No matter how complex the case, the assessment statement is typically brief. The author therefore has to make important judgments regarding what to include and exclude, and about the correct level of granularity. It is likely there are many other components to this person’s case. In the SOAP note, only the most relevant items are emphasized. The assessment, in its totality, creates a coherent clinical narrative from which the reader can quickly understand the patient context.
The assessment can be separated into 4 different tasks, corresponding to four distinct and important questions:
- Task 1: Who is the patient?
- Task 2: Why is the patient here?
- Task 3: What has happened thus far in the most recent encounter period?
- Task 4: What is the current status?
Depending on the clinical setting and context, there may be an additional or optional Task 5:
- Task 5: What remains to be done or satisfied to meet the next threshold of progression?
Let’s consider each of these tasks in the context of the example presented above.
The first task sets the stage by answering “Who is the patient?”. Typically this is written as a combination of name, age, sex, race, gender, and relevant co-morbidities, past medical history or other important qualifying or identifying information that the author finds relevant to the clinical narrative. Here the author represented task 1 as:
"Mrs. Singh is a 69 yo Indian female with HTN and poorly controlled diabetes admitted 7 days ago”
Everything in the first half of the first sentence is valuable. We learn the patient’s name and just as immediately we learn the patient's age which has great prognostic, diagnostic and treatment implications in any medical scenario. The clinician in this case indicated that the patient has hypertension and diabetes, the latter of which is poorly controlled. Almost certainly, a 69-year-old patient will have other past medical history, but not everything will be relevant to the case at hand. For example, a surgery in her youth might not be relevant. Or the patient may have a comorbidity that is well treated and in control. In this case, the clinician believed HTN and diabetes could be relevant perhaps as an identifier, or for the treatment plan, or for some other important considerations for the reader. Computers that attempt this exercise must, similarly, be able to prioritize in context.
Finally, the writer has indicated that the patient was admitted to the hospital 7 days ago – providing critical information on the clinical setting. The length of this hospitalization reveals something else as well. This is a long hospitalization, which has a number of clinical and logistical implications. Another assessment of course could indicate that the patient is arriving for an outpatient appointment or is present at a home visit or specialty procedure site.
The second task of the assessment is to explain why the patient is interacting with the healthcare system now. For example, if they are in the hospital, what is the reason for admission? If they are presenting for an outpatient visit, what is its basis? This part of the assessment provides an orientation on the main clinical concerns that generated the encounter in the first place.
“...admitted 7 days ago with an acute NSTEMI and cardiogenic shock…”
Continuing from the previous task, we know the patient was admitted to the hospital 7 days ago. We now know that the patient was admitted for a non-ST elevation myocardial infarction (NSTEMI), or heart attack, that appears severe because the patient also had associated cardiogenic shock. It’s possible that the patient had other active conditions on admission. These are not mentioned. For example, it's possible that the patient’s blood sugars or glycemic control were elevated or inappropriate. However, the author determined that this was not the principal or even a significant basis for admission. The goal is to summarize the case to its critical essence.
The cardiogenic shock reveals the severity of the patient’s NSTEMI. By mentioning it with the NSTEMI as part of the admission reason, the writer suggests that the shock state was an important consideration on admission. It is important either because it suggests the magnitude of the NSTEMI, or, independently, that the patient’s heart was so debilitated for whatever reason that the patient could not achieve effective blood flow. With this phrase, the author clearly establishes why the patient is here, and the severity of the situation on admission.
The3rd task answers the question: what has happened in this encounter or in this relevant time period? As this Assessment makes clear, quite a number of critical events occurred in this patient’s hospitalization:
“...status-post left heart catheterization with PCI to LAD and circumflex. Course complicated by a right external iliac injury during placement of intra-aortic balloon pump, subsequently resolved with successful repair of the iliac artery…”
The author indicates that the patient had a percutaneous coronary intervention (PCI) of the left anterior descending (LAD) and circumflex arteries. Clearly this was the immediate treatment for the NSTEMI. The patient also had an intra-aortic balloon pump placed, likely to treat the cardiogenic shock, and unfortunately appears to have experienced an injury to their external iliac artery during this procedure. This was a critical event in the hospitalization. The author then states that this laceration was successfully resolved through a subsequent repair of the artery. At this point in the description we don’t know how the injury specifically occurred.
It's almost certain that other, perhaps more minor, hospital events occurred. To properly orient and focus the reader, the author has to prioritize discussing events most significant for subsequent decision making. It’s also possible that under other medical scenarios, task 3 would look different. For example, on the ambulatory side, one might provide a discussion of inter-visits events or the diagnostic or therapeutic milestones.
Here, the author is communicating the patient’s current status. The 4th task often answers: how is the patient doing now? Where is the patient in their clinical journey? What are we waiting for and what still remains to be determined? In our example, the clinician wrote:
“...Patient transferred out of the ICU 2 days ago, is hemodynamically stable and beginning to ambulate.”
The first component mentioned by the author, that they transferred out of the ICU, could of course be argued as a component of task 3, since it describes what has happened in the hospitalization. However, this statement also describes the patient’s current status as someone who is “post-ICU”, with all the attendant medical nuances and vulnerabilities. Similar to what we saw in the blurring between task and task 2, task 3 and task 4 also can blend.
The remaining segment of task 4 appends additional descriptions of the current state: (1) the patient’s hemodynamics are stable (this is relevant because earlier the patient had cardiogenic shock); and (2) as a reflection of the patient’s clearly improving situation, the patient is beginning to ambulate.
Is there a Task 5? If it is mentioned, Task 5 lays out what the next most important set of goals or milestones are. If task 1 to 4 could be classified as past and present, task 5 is the future: What remains to be done or satisfied to meet the next threshold of progression?
In the hospital setting, task 5 could represent what items, actions or next steps are still remaining for discharge from the hospital. We append the Task 5 statement to our current example in blue:
Mrs. Singh is a 69 yo Indian female with HTN and poorly controlled diabetes admitted 7 days ago with an acute NSTEMI and cardiogenic shock, status-post left heart catheterization with PCI to LAD and circumflex. Course complicated by a right external iliac injury during placement of intra-aortic balloon pump, subsequently resolved with successful repair of the iliac artery. Patient transferred out of the ICU 2 days ago, is hemodynamically stable and beginning to ambulate. If the patient is cleared by Cards and PT/OT, and SNF is arranged she could be discharged today with close f/u.
Here the author states that the patient needs at least 3 key resolutions for a safe discharge: a) medical clearance by the cardiology consulting team; b) clearance by the physical therapy and occupational therapy service, and c) appropriate placement in a post-acute care skilled nursing facility.
So there you have it, an Assessment deconstructed into its 5 Tasks. In the next blog post, we will briefly discuss ornamentation or customization of the assessment based on the writer’s practice or preference, the clinical context, and the local institutional culture, protocols, or expectations.
* Note: this assessment does not represent a real patient.
Ruben Amarasingham, MD, is the founder and CEO of Pieces, Inc. He is a national expert in the design of AI products for healthcare and public health, and the use of innovative care models to reduce disparities, improve quality, and lower costs. Follow him on LinkedIn or Pieces to catch the next installation of this series.