American Health Information Management Association (AHIMA) Certification Practice Exam

Which part of the problem-oriented medical record is commonly used by facilities that have not fully adopted the problem-oriented format?

1. Problem list as an index

2. Initial plan

3. SOAP form of progress notes

4. Database

The correct answer is: SOAP form of progress notes

The SOAP form of progress notes is commonly utilized in facilities that have not fully adopted the problem-oriented format due to its structured approach to documenting patient encounters. SOAP stands for Subjective, Objective, Assessment, and Plan, which allows healthcare professionals to organize patient information methodically and systematically. In environments where the problem-oriented medical record (POMR) is not fully implemented, the SOAP format provides a clear and consistent way to record ongoing patient assessments and treatment plans. This structure aids in organizing relevant information, facilitating communication among healthcare providers, and enhancing the continuity of care, which is essential even if the entire POMR format is not utilized. While the problem list serves as an index and might be present, and the initial plan and database are critical components as well, these elements do not specifically address the common practice of using progress notes in a structured format. Thus, the SOAP note format remains a widely accepted approach for documenting clinical information, making it particularly valuable in hybrid or transitional documentation settings.