The SNOCAMP note is similar to the SOAP note used in the health care profession to document patient visits. The note covers the same four categories as the SOAP note with the addition of three more categories. The letters stand for the following:
The move to the SNOCAMP note from the SOAP note has been encouraged by both the increased number of medical malpractice lawsuits
, as well as more strict documentation requirements for reimbursement
from medical insurance companies. Below is a more detailed list of what the seven categories contain.
The subjective portion of the notes contains what information you receive from the patient. It may include
In this section you try to document
everything possible that might shed light on a patient's condition.
Nature of Illness
How complex or severe is the patient's illness, or how potentially severe could the presenting symptoms turn out to prove?
This is the physical examination portion. Vital signs, general appearance, and other findings on direct examination of the patient should be putin this section
Here is where documentation is placed regarding the discussions with the patient about medication, procedures, risks of treating (or of NOT treating), and alternatives to the recommended plan.
and any speculation
are placed in this section. Sometimes, a diagnosis hasn't been made, and the section consists of a list of differential diagnoses
for the symptoms the patient has had.
Medical decision making
This section is purely documenting information required by the insurance companies, Medicare, and Medicaid (or the various government equivalents of countries other than the US).
Simply put, what does the medical professional intend to do about the problem
or problems listed in the assessment section? Here's where that is documented.
See also: SOAP note