2020 Volume 9 Pages 146-153
Subjective, objective, assessment, and plan (SOAP) notes are widely used by physicians to document clinical reasoning in assessing, diagnosing, and treating patients. SOAP notes are also used in medical coding tasks for reimbursement of insurance claims. In Indonesia, medical coders who are independent from physicians assess SOAP notes to assign diagnostic codes and medical procedure codes based on the corresponding International Classification of Diseases standards. Discrepancies between physicians who write the SOAP notes and coders who assign diagnoses and treatments, may occur. These discrepancies were assessed by performing a video-based survey to understand the coder's perspective, allowing the development of a writing support system to achieve unproblematic SOAP notes. This survey found that problematic SOAP notes were not caused by a single problem but by multiple problems. Abbreviations used by physicians are the major problem in assigning diagnostic codes, whereas incomplete data are the major problem in determining planning. This survey also showed that problematic SOAP notes may contain helpful keywords for coders that can help in determining diagnosis and treatment. The findings show that the system should be able to recognize separate sections of the SOAP note to provide writing support features and identify helpful keywords to encourage physicians to write unproblematic SOAP notes.