Charting Templates, Macros, & SOAP Notes
Chart smarter, not harder!
You may also be interested in this read: SOAP Notes for NPs - Documentation Essentials.
We are living in an era where many of us are using AI to help document more quickly - and yes, it does save a lot of time during a busy clinic day. AI Scribes are AI-powered tools that automatically capture, summarize, and record clinical encounters between a patient and clinicians in real time (1). AI tools are streamlining intake and triage processes, support clinical decision making, and alleviate administrative burdens we all face as clinicians. But it is meant to compliment, not replace, clinical judgement.
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As we know, AI Scribes can produce false or inaccurate content, and if it is trained on biased or incomplete data, it risks reinforcing disparities in care (1,2). Leaning too heavily on AI-generated notes could dull our critical thinking skills and make it harder to pick up on subtle patient cues (2). There is also a concern for “alert fatigue” - where AI proposes too many alerts - especially false positives - which can overwhelm clinicians causing important information to be overlooked (2). While privacy and confidentiality concerns remain within healthcare’s heavy regulations, getting AI applications approved and into practice can be a long, complicated road (2).
Templates/Macros using the SOAP format
In my own practice, I have not adopted AI Scribe, although I’m not against it. Instead, I’ve adopted the use of charting templates, commonly referred to as macros, using the SOAP note format. It does help me chart more quickly, but customizing my own templates has also helped me reflect on the diagnostic process with various presentations. When customizing my templates, I ask myself:
What diagnostic framework(s) will I use for this presentation?
With my diagnostic framework, what are my must-not-miss diagnoses, or red flag presentations?
What history questions are pertinent to help adjust my pre-test probability for the differentials I’ve come up with?
What physical exam tests are necessary to rule in and rule out various differentials?
Templates can help cue our memory into remembering what differentials to consider, thus guiding our history, physical exam, and other tests. I also find that creating/customizing and updating these templates anchor my knowledge of disease.
Masterclass members get access to 100+ customizable charting templates 👉 Check out our charting templates preview.
Lastly, I use the SOAP format - Subjective, Objective, Assessment, and Plan, to outline my charting template. You can check out a SOAP example here. Then I can input it into an electronic medical record (EMR) to use as a blank slate with patients presenting with various concerns. I’ve created over 100 charting templates since I started practicing as an NP, which has not only helped with learning and reflecting on clinical presentations, but has also sped up my charting.
BUT, like AI Scribes, charting templates are NOT fool-proof. Just like algorithms and guidelines are not fool proof in medicine, we must rely on the power of our own diagnostic reasoning (which is what this blog is all about!) to diagnose and treat patients. At the end of the day, there are many tools we can utilize to offset cognitive workload, but we must not solely rely on them.
Check out this video, briefly walking you through one of my SOAP note charting templates:
💡 Key Take Home Point: whether you are using AI Scribe, or templates to offset cognitive workload, remember - rely on your diagnostic reasoning skills to get to the bottom of your patients’ presentation.