Which statement correctly contrasts SOAP notes with a problem-oriented medical record?

Which statement correctly contrasts SOAP notes with a problem-oriented medical record?

• A. SOAP organizes records by problem with a database and progress notes.
• B. SOAP uses the four-part structure Subjective, Objective, Assessment, Plan.
• C. Problem-oriented records organize by problem with a database, problem list, initial plan, and progress notes.
• D. For a new presentation, documentation includes HPI, ROS, and PE only.

Answer: (C)

The main idea being tested is how a problem-oriented medical record is organized around problems rather than around a single encounter. In a POMR, you start with a database of all available information, create a running problem list, develop an initial plan for those problems, and then update progress with progress notes tied to each problem. That structure is what makes POMR distinct: it tracks issues across time and organizes the chart by problem. SOAP notes, by contrast, present documentation for an encounter in four parts—Subjective, Objective, Assessment, and Plan—focusing on the information gathered and conclusions for that visit. While SOAP can be used within the progress notes of a POMR, the defining organization described here is the problem-centric arrangement of POMR. Therefore, the statement that problem-oriented records organize by problem with a database, problem list, initial plan, and progress notes accurately describes POMR.

The main idea being tested is how a problem-oriented medical record is organized around problems rather than around a single encounter. In a POMR, you start with a database of all available information, create a running problem list, develop an initial plan for those problems, and then update progress with progress notes tied to each problem. That structure is what makes POMR distinct: it tracks issues across time and organizes the chart by problem.

SOAP notes, by contrast, present documentation for an encounter in four parts—Subjective, Objective, Assessment, and Plan—focusing on the information gathered and conclusions for that visit. While SOAP can be used within the progress notes of a POMR, the defining organization described here is the problem-centric arrangement of POMR.

Therefore, the statement that problem-oriented records organize by problem with a database, problem list, initial plan, and progress notes accurately describes POMR.