introduction

Background

soapnote was created to address a problem. Calculators, boilerplate, clinical decision rules, and checklists that providers use in their daily practice are often piled into proprietary electronic health record silos (link: http://bit.ly/eLaIRu), personal disc drives, paper forms, and in some cases, paper notes.

This untapped information has value. Exchange of this information is a valuable endeavor.

A SOAP note (link: http://bit.ly/gVpFva) is a form of clinical documentation often used for progress notes. SOAP is an acronym for Subjective (history), Objective (examination), Assessment (diagnosis), and Plan (treatment) components of the note.

soapnote is a website intended for use by medical providers to create, collaborate, and catalogue clinical decision tools. In this reference, “soapnote” refers to any clinical decision tool on the site.

Core principles

The development of soapnote is guided by some core principles.

D-R-Y (Don’t Repeat Yourself; link: http://bit.ly/fripkU) so you can focus on duties that require more thought.
Checklists jog your memory and make care better (link: http://1.usa.gov/fzzcFG).
Writing computer-based clinical decision support needs to be as simple as possible.
Medical providers must be able to exchange clinical decision tools.
The soapnotes on the website should be compatible with all electronic health records.
This should be free to use for everyone.

Features of the website

It is an online database of generic SOAP note text, web forms, calculators, and other clinical decision tools for a variety of diagnoses/complaints.
It is annotated and searchable.
Users may review, edit, and collaborate online.
Bookmarking: Users can save their favorite content (soapnotes).
Voting: Raters can indicate whether or not a soapnote was useful to them.
Commenting: Each soapnote can also be a discussion.
Tagging: Users can organize and find related soapnotes.
Emphasis is placed on recent, highly utilized, and highly rated soaps.
Social: There are multiple ways to share content.
Evidence Based: soapnotes are linked to and annotated with evidence.

What exactly is a “soapnote”?

It could be as simple as a checklist or as involved as a paragraph builder with some decision support (including calculations). Anything that speeds up your clinical visits, makes the care you provide more consistent, improves the depth of your documentation, or simply helps you not forget an important step.

Where do these soapnotes come from?

The purpose of soapnote is to allow providers to spend more of their time thinking about “hard stuff” and less time re-inventing the wheel. Here are some sources you can use to make good templates:

import your medical templates from dictation programs such as Shorthand for Windows (link: http://bit.ly/eloP18)
paraphrase your best old notes
build from your favorite evidence sources
collaborate to make templates as an educational exercise
and any other ways you can think of…

Is there anything that should not be in a soapnote?

Yes. It is critical that there is no identifying information present in the templates. This information MUST be removed before posting a template to this site. For further reference, there are some guidelines from the Health Insurance Portability and Accountability Act (HIPAA; link: http://bit.ly/e9XpCl). The following is a list of identifiers that must be removed to de-identify medical data per HIPAA.

Names
Geographic subdivisions smaller than a State *
All elements of dates (except year)
All ages over 89 *
Telephone numbers
Fax numbers
Electronic mail addresses
Social security numbers
Medical record numbers
Health plan beneficiary numbers
Account numbers
Certificate/license numbers
Vehicle identifiers and serial numbers, including license plate numbers
Device identifiers and serial numbers
Web Universal Resource Locators (URLs)
Internet Protocol (IP) address numbers
Biometric identifiers, including finger and voice prints
Full face photographic images and any comparable images
Any other unique identifying number, characteristic, or code

* Additional details are given in the regulation text. Note that these categories refer only to identifiers that concern an individual, their relatives, employers or household members.

Ingredients for making soapnotes

As mentioned above, there are a lot of sources for making soapnotes.
The American Association of Family Physicians journal Family Practice Management has produced a document of common visits, including the top 100 most common visits. This is called the ”FPM Long List” (link: http://bit.ly/dSeSdi).

From this list, a worksheet was produced as a roadmap for soapnote. This list includes relevant articles from the American Family Physician and BMJ’s Clinical Evidence Concise. In addition, relevant AMA performance measures (link:http://bit.ly/enZvYI) are included for a few conditions to ensure that these will be included in those few templates.

The worksheet may be viewed on Google’s Fusion Tables (link: http://bit.ly/dVsDhI). You can also leave your comments and suggestions in that table, if you’d like. If you’d like to contribute to the table, please let us know and we can help set that up (email: mark@soapnote.org).

What’s the fine print?

There are some Terms and Conditions which you should peruse (meaning: read thoroughly). Your use of this website implies that you have read and accepted these Terms and Conditions.

Introduction

The Soapnote website strives to offer reliable reference materials to medical professionals. Readers outside the medical profession are welcome to use this website as a resource; this should, however, not be interpreted as medical advice, and does not in any way replace professional medical care. Patients should always address specific medical concerns with their physicians.

The following terms and conditions govern all use of the Soapnote website and all content, services and products available at or through the website. The Website is offered subject to your acceptance without modification of all of the terms and conditions contained herein and all other operating rules, policies (including, without limitation, the Soapnote Privacy Policy).

Please read this Agreement carefully before accessing or using the Website. By accessing or using any part of the web site, you agree to become bound by the terms and conditions of this agreement. If you do not agree to all the terms and conditions of this agreement, then you may not access the Website or use any services. If these terms and conditions are considered an offer by Soapnote, acceptance is expressly limited to these terms.

Ownership

You may not assert ownership and copyright of your posts. You may not claim intellectual property right or exclusive ownership to any of our products, modified or unmodified. Our products are provided ‘as is’ without warranty of any kind, either expressed or implied. In no event shall Soapnote be liable for any damages including, but not limited to, direct, indirect, special, punitive, incidental or consequential, or other losses arising out of the use of or inability to use our products.

Your Soapnote Account.

You must immediately notify Soapnote of any unauthorized uses of your account or any other breaches of security. Soapnote will not be liable for any acts or omissions by you, including any damages of any kind incurred as a result of such acts or omissions.

Responsibility of Contributors.

If you comment on a website, post material to the website, post links on the website, or otherwise make (or allow any third party to make) material available by means of the website (any such material, ‘Content’), You are entirely responsible for the content of, and any harm resulting from, that Content. That is the case regardless of whether the Content in question constitutes text, graphics, an audio file, or computer software. By making Content available, you represent and warrant that:

the downloading, copying and use of the Content will not infringe the proprietary rights, including but not limited to the copyright, patent, trademark or trade secret rights, of any third party;
you have fully complied with any third-party licenses relating to the Content, and have done all things necessary to successfully pass through to end users any required terms;
the Content does not contain or install any viruses, worms, malware, Trojan horses or other harmful or destructive content;
the Content is not spam, is not machine- or randomly-generated, and does not contain unethical or unwanted commercial content designed to drive traffic to third party sites or boost the search engine rankings of third party sites, or to further unlawful acts (such as phishing) or mislead recipients as to the source of the material (such as spoofing);
the Content is not obscene, libelous or defamatory, hateful or racially or ethnically objectionable, and does not violate the privacy or publicity rights of any third party;
you have, in the case of Content that includes computer code, accurately categorized and/or described the type, nature, uses and effects of the materials, whether requested to do so by Soapnote or otherwise.

If you delete Content, Soapnote will use reasonable efforts to remove it from the Website, but you acknowledge that caching or references to the Content may not be made immediately unavailable.

Without limiting any of those representations or warranties, Soapnote has the right (though not the obligation) to, in Soapnote’s sole discretion (i) refuse or remove any content that, in Soapnote’s reasonable opinion, violates any Soapnote policy or is in any way harmful or objectionable, or (ii) terminate or deny access to and use of the Website to any individual or entity for any reason, in Soapnote’s sole discretion. Soapnote will have no obligation to provide a refund or remuneration for any losses.

Responsibility of Website Visitors.

Soapnote will attempt to edit, but cannot make any guarantee of review of all the material, including computer software, posted to the Website, and cannot therefore be responsible for that material’s content, use or effects.

The user of this website assumes complete responsibility in applying any management strategies documented here. Healthcare professionals need to use their own clinical judgement in interpreting this medical information, and details such as medication dosages or laboratory normal values should always be confirmed with other resources.

By operating the Website, Soapnote does not represent or imply that it endorses the material there posted, or that it believes such material to be accurate, useful or non-harmful. You are responsible for taking precautions as necessary to protect yourself and your computer systems from viruses, worms, Trojan horses, and other harmful or destructive content. The Website may contain content that is offensive, indecent, or otherwise objectionable, as well as content containing technical inaccuracies, typographical mistakes, and other errors. The Website may also contain material that violates the privacy or publicity rights, or infringes the intellectual property and other proprietary rights, of third parties, or the downloading, copying or use of which is subject to additional terms and conditions, stated or unstated. Soapnote disclaims any responsibility for any harm resulting from the use by visitors of the Website, or from any downloading by those visitors of content there posted.

Content Posted on Other Websites.

We have not reviewed, and cannot review, all of the material, including computer software, made available through the websites and WebPages to which Soapnote links, and that link to Soapnote. Soapnote does not have any control over those non-Soapnote websites and WebPages, and is not responsible for their contents or their use. By linking to a non-Soapnote website or webpage, Soapnote does not represent or imply that it endorses such website or webpage. You are responsible for taking precautions as necessary to protect yourself and your computer systems from viruses, worms, Trojan horses, and other harmful or destructive content. Soapnote disclaims any responsibility for any harm resulting from your use of non-Soapnote websites and WebPages.

Copyright Infringement and DMCA Policy.

As Soapnote asks others to respect its intellectual property rights, it respects the intellectual property rights of others. If you believe that material located on or linked to by Soapnote violates your copyright, you are encouraged to notify Soapnote. Soapnote will respond to all such notices, including as required or appropriate by removing the infringing material or disabling all links to the infringing material. In the case of a visitor who may infringe or repeatedly infringes the copyrights or other intellectual property rights of Soapnote or others, Soapnote may, in its discretion, terminate or deny access to and use of the Website. In the case of such termination, Soapnote will have no obligation to provide a refund of any amounts previously paid to Soapnote.

Intellectual Property.

This Agreement does not transfer from Soapnote to you any Soapnote or third party intellectual property, and all right, title and interest in and to such property will remain (as between the parties) solely with Soapnote. Soapnote, www.soapnote.org, www.soapnote.net, the Soapnote logo, and all other trademarks, service marks, graphics and logos used in connection with Soapnote, or the Website are trademarks or registered trademarks of Soapnote or Soapnote’s licensors. Other trademarks, service marks, graphics and logos used in connection with the Website may be the trademarks of other third parties. Your use of the Website grants you no right or license to reproduce or otherwise use any Soapnote or third-party trademarks.

Changes.

Soapnote reserves the right, at its sole discretion, to modify or replace any part of this Agreement. It is your responsibility to check this Agreement periodically for changes. Your continued use of or access to the Website following the posting of any changes to this Agreement constitutes acceptance of those changes. Soapnote may also, in the future, offer new services and/or features through the Website (including, the release of new tools and resources). Such new features and/or services shall be subject to the terms and conditions of this Agreement.

Termination.

Soapnote may terminate your access to all or any part of the Website at any time, with or without cause, with or without notice, effective immediately. If you wish to terminate this Agreement or your Soapnote account (if you have one), you may simply discontinue using the Website. Notwithstanding the foregoing, if you have a VIP Services account, such account can only be terminated by Soapnote if you materially breach this Agreement and fail to cure such breach within thirty (30) days from Soapnote’s notice to you thereof; provided that, Soapnote can terminate the Website immediately as part of a general shut down of our service. All provisions of this Agreement which by their nature should survive termination shall survive termination, including, without limitation, ownership provisions, warranty disclaimers, indemnity and limitations of liability.

Disclaimer of Warranties.

The materials on Soapnote’s web site are provided ‘as is’. Soapnote makes no warranties, expressed or implied, and hereby disclaims and negates all other warranties, including without limitation, implied warranties or conditions of merchantability, fitness for a particular purpose, or non-infringement of intellectual property or other violation of rights. Further, Soapnote does not warrant or make any representations concerning the accuracy, likely results, or reliability of the use of the materials on its Internet web site or otherwise relating to such materials or on any sites linked to this site.

Limitation of Liability.

In no event will Soapnote, or its suppliers or licensors, be liable with respect to any subject matter of this agreement under any contract, negligence, strict liability or other legal or equitable theory for: (i) any special, incidental or consequential damages; (ii) the cost of procurement or substitute products or services; (iii) for interruption of use or loss or corruption of data; or (iv) for any amounts that exceed the fees paid by you to Soapnote under this agreement during the twelve (12) month period prior to the cause of action. Soapnote shall have no liability for any failure or delay due to matters beyond their reasonable control. The foregoing shall not apply to the extent prohibited by applicable law.

General Representation and Warranty.

You represent and warrant that (i) your use of the Website will be in strict accordance with the Soapnote Privacy Policy, with this Agreement and with all applicable laws and regulations (including without limitation any local laws or regulations in your country, state, city, or other governmental area, regarding online conduct and acceptable content, and including all applicable laws regarding the transmission of technical data exported from the country in which you reside) and (ii) your use of the Website will not infringe or misappropriate the intellectual property rights of any third party.

Indemnification.

You agree to indemnify and hold harmless Soapnote, its contractors, and its licensors, and their respective directors, officers, employees and agents from and against any and all claims and expenses, including attorneys fees, arising out of your use of the Website, including but not limited to out of your violation this Agreement.

Site Terms of Use Modifications

Soapnote may revise these terms of use for its web site at any time without notice. By using this web site you are agreeing to be bound by the then current version of these Terms and Conditions of Use.