EHR Integrations and Templates for Medical Specialties
AI-Powered SOAP Note Generator — an Overview
Sixty years after physicians first began exploring the concept of a formal, electronic medical record for each patient, a fundamental challenge at the heart of medicine remains front and center: How can doctors document care quickly and accurately across multiple specialties?
Today, the Electronic Medical Record (EMR) remains the clinical core of the larger Electronic Health Record (EHR), which encompasses records, data analytics, Revenue Cycle Management, and tools for everything from interoperability to Patient Engagement, Population Health, and Value-Based Care.
But the EMR — and documentation of the patient encounter — remains the first and most important element for practices of every size and type. It is no surprise, then, that advances in documentation have mirrored advances elsewhere in medicine.
The latest chapter in documentation features electronic medical scribes — more specifically, medical scribes such as Sunoh.ai, which are powered by artificial intelligence and rely upon advanced speech recognition algorithms and natural language processing.
Before taking a closer look at the power and versatility of Sunoh’s AI medical scribe, however, a short history lesson can serve as a useful reminder of what matters in medical documentation. That, in turn, can guide decision-makers as they consider the features and options that various AI medical scribes have to offer.
The Origin of SOAP Notes: Focusing on Patients
As early as 1964, Dr. Lawrence Weed introduced the concept of the EMR. Four years later, in an article in The New England Journal of Medicine, Dr. Weed wrote that clinical clerks and practicing physicians alike are “confronted with conditions that are frustrating in every phase of medical action.”
“To deal effectively with these frustrations,” Weed wrote, “it will be necessary to develop a more organized approach to the medical record, a more rational acceptance and use of paramedical personnel and a more positive attitude about the computer in medicine.”
As Dr. Weed noted in a 1971 speech on conducting medical rounds, the medical record does matter: “You’re a victim of it, or you’re a triumph because of it. The human mind simply cannot carry all the information about all the patients in the practice without error.”
Needless to say, in the decades since then notes are no longer just used for a physicians own personal reference while practicing. As medical records went electronic, they became easier to share and the audience of a progress note grew to include coders, payers, care managers, compliance monitors, research organizations, and the patients themselves. The need for an encounter note to satisfy all these different stakeholders has resulted in notes growing in size and complexity to the point that patients commonly complain that their provider spends more time typing at the keyboard than having a conversation with them.
What Are SOAP Notes?
Dr. Weed’s ideas soon took hold and gave rise to what physicians then and now call the SOAP note, an acronym for “Subjective, Objective, Assessment, and Plan.”
At the most basic level, SOAP notes provide a structured format for documenting patient encounters. They are used by a wide range of healthcare professionals, including physicians, nurses, and therapists.
Perhaps the most important aspect of SOAP notes is that they bring a measure of uniformity to medicine, enabling providers to store, analyze, and, when necessary, share patient data in structured form. That can mean a deeper understanding of patients’ needs, more accurate diagnoses, and better treatments and outcomes.
SOAP Notes or DAP Notes?
But not all medical notes are created equal.
SOAP notes are the most comprehensive and widely used format, include a detailed patient history and physical exam, and are generally used by family and general practitioners as well as many specialists.
- The subjective section captures the patient’s history of present illness.
- The objective section includes physical exam findings and vital signs.
- The assessment section includes the provider’s diagnosis and reasoning.
- The plan section details the treatment plan, medications, orders, and follow-up.
Behavioral and mental health providers, on the other hand, generally use DAP notes — an acronym for “Data, Assessment, Plan” — that focus more on the patient’s current symptoms and progress.
- The data section includes patient statements and observations.
- The assessment section contains the provider’s diagnosis and impressions.
- The plan section outlines the treatment plan and next steps.
DAP notes are typically shorter and more concise than SOAP notes and are best suited for documenting therapy sessions and mental health visits. They are generally not used for documenting medical procedures.
Flexibility Across Note Types and Specialties
While different providers might favor different types of notes, what about the medical organization that might need any and all varieties of notes, but would like a single cost-effective solution? That’s where Sunoh comes in.
Sunoh’s AI-powered SOAP note generator supports SOAP notes, DAP notes, and shorter procedural notes and can seamlessly switch between note types based upon the specialty and the type of visit. That versatility saves providers time since they do not have to switch between solutions or products.
The Challenges of Traditional SOAP Note Creation
The first and most obvious advantage of Sunoh is, of course, the fact that it is an AI-powered medical dictation and transcription product. Physicians who are older or may now be retired will recall the days of manual documentation.
With no computer in sight, physicians used to spend a great deal of time taking notes, trying to keep up with their patients’ needs, and then struggling to remember the details of each encounter. Unsurprisingly, such processes led to inconsistencies and errors.
As practices grow and providers see more patients, that challenge grows accordingly, making the adoption of an EMR essential. And today’s complex medical environment means that the EMR and EHR must grow in sophistication in order to deliver the quality results that patients expect and providers demand of themselves.
In short, while the tools of 2024 are light-years ahead of those of the 1960s and ’70s, the end goal remains that identified by Dr. Weed in his 1971 speech: “What I’d like to do is go at this problem not from the point of view of the record — I mean, we really aren’t taking care of records. We’re taking care of people. And we’re trying to get across the idea that this record cannot be separated from the caring of that patient.”
How Sunoh.ai’s AI SOAP Note Generator Works
It is true, of course, that the many technological advances of recent decades have yielded products that can deliver much greater insight into the health needs of patients.
In that light, Sunoh.ai is a product whose time has come. Among its capabilities, it:
- Utilizes advanced natural language processing (NLP) and machine learning algorithms
- Generates comprehensive SOAP notes from shorthand notes, dictation, or audio recordings
- Offers customizable templates for different specialties and note types
- Automatically maps subjective and objective findings to the appropriate SOAP note sections
- Extracts relevant information from the patient’s history of present illness (HPI)
- Identifies and documents the assessment and plan, including medications, orders, and follow-up
Specialty-Specific Medical SOAP Note Templates
Here, for each of several specialties, are some of the key features that Sunoh offers providers:
Optometry/Ophthalmology
- Customizable templates for eye exams
- “Right eye, left eye” grid format
- The ability to switch between optometry exams and ophthalmology surgical notes
Dentistry
- Templates for dental exams and procedure notes
- A periodontal charting feature that eliminates the need for a second person in the exam room
- Streamlined documentation for dental hygienists
Orthopedics
- Templates for both office visits and surgical procedures
- Capture of the patient’s detailed History of Present Illness (HPI)
- Generation of concise orthopedic procedure notes
Gastroenterology
- Templates for office visits and endoscopy procedure notes
- Documentation of the physician’s monologue during procedures
- Support for other procedure-heavy specialties such as general surgery and pain management
Behavioral/Mental Health
- Support for DAP (Data, Assessment, Plan) notes
- Flexibility to handle both SOAP and DAP note formats
- Mapping of information to appropriate DAP sections based on the provider’s dictation
Pediatrics
- Templates for comprehensive pediatric visits
- Ability to capture multiple speakers, including parents and children
- Documentation of key elements, including allergies, medications, and patient instructions
Emergency Medicine
- Customizable templates for the fast-paced emergency room environment
- A streamlined SOAP note format to capture essential information quickly
- Integration with hospital EHR systems for seamless documentation
Rheumatology
- Specific templates for joint exams and a homunculus model view
- Documentation of findings in a structured format
- Integration with rheumatology-specific EHR modules
Dermatology
- Use of a 3D, hot-spotted model for documenting skin findings
- The ability for providers to quickly map observations to specific body areas
- Generation of comprehensive dermatology visit notes
Benefits for Healthcare Providers
The first and most impactful benefit of an AI Progress Note generator is the time that it saves for providers. Recent studies from a wide variety of organizations, including the American Medical Association, consistently show that half or more of all providers are exhibiting at least some symptoms of burnout.
Since its introduction a year ago, Sunoh has been adopted by more than 50,000 providers nationwide. And many users report that Sunoh’s use for documenting patient visits is saving them up to two hours per provider per day.
That’s time that providers can spend much more productively, whether in face-to-face conversations with their patients, engaging in staff training, or learning new software products to become more efficient overall.
The first and most quantifiable impact, however, is an improvement in the accuracy, completeness, and time needed to complete daily documentation. In short, practices that used to spend many hours each day trying to catch up to past visits are now finding they can complete documentation the same day and generally are done with the day’s documentation before it’s time to head home.
That points to another major benefit of AI medical scribes and Progress Note generators: They are having a real impact on the quality of life for physicians and staff. The number of hours in the day hasn’t changed, of course, but with fewer administrative headaches, work/life balance is improving. Providers have more time to spend with their families and friends or on their hobbies and favorite pastimes.
EHR Integration, Interoperability, Enhanced Efficiency
We hope that physicians start each day refreshed and with an appreciation for the value of the healthcare IT tools they use. But it never hurts to recap some of the advantages that AI-powered medical scribes deliver.
In Sunoh’s case, they include:
- An EHR-agnostic design that offers integration with leading EHRs, including Epic and Cerner, and close native integration with eClinicalWorks
- Automatic importation of generated SOAP notes directly into the patient’s medical chart
- Support for Computerized Physician Order Entry (CPOE) for medications, labs, and imaging
- Utilization of FHIR and HL7 interoperability standards for compatibility with various EHRs
- Multilingual support for English, Spanish, and Portuguese
- Mobile-friendly apps for iOS and Android devices
- Automatic generation of patient instructions and after-visit summaries
- Compliance with HIPAA requirements and security features that ensure the privacy of protected health information (PHI)
