Quality of subjective, objective, assessment, and plan-based clinical documentation and its predictive value on treatment planning in excisional biopsy cases: A retrospective study

INTRODUCTION

Accurate and structured documentation is foundational to safe, effective, and legally sound clinical care. High-quality records ensure continuity of care, enabling effective communication between healthcare providers. They also serve as critical evidence in medicolegal contexts.^[1] Inadequate or inconsistent documentation may contribute to diagnostic errors, delayed treatment, compromised patient safety, and increased risk of litigation. Clinical documentation audits are vital because they help identify gaps, ensure compliance with standards, and guide necessary improvements.^[2] Regular audits maintain high standards of care by ensuring thorough records. They also improve compliance with regulatory guidelines, enhance patient safety through better communication, and provide legal protection by serving as comprehensive records of care.^[3] Numerous authors have highlighted that poor-quality information in clinical records indicates suboptimal care. It is also strongly associated with a higher incidence of adverse patient safety events.^[4,5] Inadequate documentation can lead to miscommunication, diagnostic errors, inappropriate treatments, and legal complications.^[6]

Several tools have been developed to assess clinical documentation. These include the subjective, objective, assessment, and plan (SOAP) format, a surgical tool for auditing records, and the CRAig and BELl (CRABEL) score.^[7] They vary in complexity and focus. Some rely on manual checklists, while others use advanced software to evaluate records.^[8] Common methods include chart audits to assess the completeness of records. Automated software is used to flag issues such as missing data or coding inconsistencies.^[9] Peer reviews and clinical dashboards also provide continuous monitoring of healthcare practices, highlighting areas that need improvement.^[10] These tools play a significant role in promoting consistent, high-quality documentation, ensuring adherence to clinical and regulatory standards.

The SOAP format is one of the most widely adopted and standardized frameworks for recording patient encounters. The SOAP format offers a structured approach for documentation.^[11] It records the patient’s reported symptoms, findings from the examination, the clinician’s evaluation, and the proposed treatment.^[12] This structure supports accurate record-keeping, facilitates clinical decision-making, and strengthens interprofessional communication. SOAP format enables systematic review of records, identifies missing information, and provides a clear framework for improvement.^[13]

Although SOAP documentation is known to improve record quality, few studies have examined its impact on treatment planning. This is especially important in surgical settings, where accurate diagnosis guides appropriate treatment. This study aims to evaluate the completeness and quality of SOAP-based documentation in excisional biopsy cases and to determine its predictive value on the quality of treatment planning. By developing a quantitative scoring system and incorporating expert assessment of treatment plans, the study provides insights into how structured documentation influences clinical decision-making and care quality.

MATERIALS AND METHODS

The study aimed to evaluate the quality and completeness of clinical documentation using the SOAP format.

RESULTS

DQS

The mean DQS for the Subjective and Assessment components was 2.00 ± 0.00, indicating consistently complete documentation. The Objective component had the lowest mean score of 1.43 ± 0.63, while the plan component scored 1.88 ± 0.37. The overall mean total DQS across all 156 records was 7.31 ± 0.51. These results have been visually represented in Figure 1

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Figure 1:

Mean documentation quality score (DQS) by subjective, objective, assessment, and plan (SOAP) component. Bar chart representing the mean documentation quality score for each SOAP section. Subjective and assessment sections had complete scores (2.00), while the Objective component showed the lowest mean score, highlighting it as the least consistently documented area.

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Expert ratings of treatment plan quality

Across the 156 records, treatment plans were rated as “Excellent” in 9.6% of cases, “Good” in 42.9%, “Satisfactory” in 39.7%, and “Marginal or Inadequate” in 7.7%. The average treatment plan rating was 4.1 ± 0.62. These ratings have been illustrated in Figure 2, showing a clear skew toward satisfactory and good planning quality. The inter-rater reliability among the three expert evaluators was high (Cohen’s kappa = 0.82), indicating strong agreement.

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Figure 2:

Distribution of expert ratings for treatment plan quality. Graphical representation of the expert Likert-scale ratings assigned to treatment plans across 156 excisional biopsy cases. The majority of plans were rated as “Good” (4) or “Satisfactory” (3), indicating an overall moderate to high quality of treatment documentation.

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Regression analysis of individual SOAP components

Simple linear regression was performed to assess the predictive value of individual SOAP components on treatment plan quality. Regression analysis revealed that among all SOAP components, only the Objective section significantly predicted treatment planning quality (b = 0.33, P = 0.002). The Subjective (b = 0.07, P = 0.213), Assessment (b = 0.04, P = 0.321), and Plan (b = 0.19, P = 0.059) components were not statistically significant predictors. The model had an R² value of 0.168, indicating that documentation quality in the Objective component explained approximately 17% of the variance in treatment plan ratings. This relationship has been visualized in Figure 3.

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Figure 3:

Regression analysis: Objective documentation quality score (DQS) versus treatment plan quality. Scatter plot showing the linear regression between the Objective component score and expert-rated treatment plan quality. A moderate positive relationship was observed (β = 0.33, P = 0.002), with the regression line and R² value indicating the predictive significance of objective documentation on treatment planning.

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DISCUSSION

Structured clinical documentation is an essential component of effective patient care. It supports accurate diagnosis, safe treatment planning, and legal accountability.^[14] This study evaluated the quality of SOAP-based documentation in excisional biopsy cases and explored its predictive value for treatment planning quality. The findings affirm that the importance of documentation structure is not only as a communication tool but also as a measurable factor influencing clinical decision-making.

The Subjective and Assessment components showed complete documentation in all cases. This indicates consistent reliability of history-taking and diagnostic reasoning among clinicians. Accurate recording of demographic details, patient history, and diagnostic information is crucial for safe and effective decision-making.^[15] These findings are consistent with Nguyen et al. (2021),^[16] who emphasized that structured documentation formats like SOAP minimize errors and enhance communication among healthcare providers.^[16]

The Objective section, however, showed the lowest level of completeness, particularly for procedural findings. This inconsistency likely reflects variability in case complexity, documentation habits, and a lack of standardized protocols for surgical data entry. Challenges in maintaining thorough records are mainly due to time constraints faced by clinicians and the clinical irrelevance of some information in certain cases.^[17,18] Imaging and laboratory investigations were consistently documented when performed, showing reliability in objective data recording. However, missing data in oral surgery and follow-up information indicate a need for targeted strategies to enhance documentation consistency.^[19] This is particularly critical in cases of oral squamous cell carcinoma, where comprehensive documentation impacts diagnosis, treatment planning, and long-term monitoring.^[20-22] A study suggests that variability often stems from the lack of standardized templates.^[23] In addition, it was found that improving staff knowledge and motivation significantly enhanced SOAP documentation quality, indicating that targeted training programs can be beneficial.^[24]

The introduction of a structured DQS allowed objective measurement of SOAP documentation. A moderate and statistically significant correlation was observed between total DQS and treatment plan ratings. This finding highlights the clinical importance of thorough documentation. Among all components, the Objective section emerged as a statistically significant predictor of treatment planning quality. This emphasizes the crucial role of recording clinical findings, imaging results, and intraoperative observations in guiding therapeutic decisions.

High-quality documentation enhances the clarity, justification, and completeness of treatment plans. The strong inter-rater reliability among expert evaluators (k = 0.82) validates the robustness of the assessment methodology used in this study. A moderate positive correlation (r = 0.41, P < 0.001) was observed between total DQS and treatment plan ratings. Regression analysis identified the Objective component as a statistically significant predictor (P = 0.002). This finding aligns with Breen-Franklin (2023), who highlighted that while structured formats such as SOAP improve data organization, treatment planning is also influenced by clinician expertise and institutional protocols.^[25] Addressing these gaps through technology, such as SOAP.AI, could further integrate objective data into decision-making processes.^[26] These records will ensure that healthcare providers make informed decisions, particularly in surgical cases where precise documentation of procedures and follow-ups is crucial.^[27] Structured documentation strengthens patient safety, promotes continuity of care, and reduces medicolegal risks.^[28]

Structured documentation using SOAP format is not only essential for enhancing individual patient outcomes but also for advancing institutional standards and regulatory compliance. The adoption of electronic health record (EHR) systems has been shown to standardize documentation and reduce inconsistencies.^[29] Regular staff training along with EHR systems can help achieve higher levels of documentation completeness across all SOAP categories.

The importance of structured documentation extends beyond individual disciplines. Peer discussions in graduate nursing education have significantly enhanced the quality of SOAP notes by promoting deeper understanding and consistent application of the format.^[30] Similarly, another study found that the SOAP format significantly improved pediatric ward documentation, highlighting its versatility across clinical contexts.^[14]

Adapting SOAP documentation for evolving clinical needs is essential. Transitioning to hybrid formats like consult notes can address specific workflow requirements while retaining SOAP’s strengths.^[31] In multidisciplinary practice, this approach fosters clearer communication and continuity of care. Integrating structured learning into clinical decision-making highlights SOAP’s value not just as a recording tool but as a framework for systematic thinking and comprehensive care.^[32]

The limitations of this study include its retrospective design, reliance on a single institution’s data, and exclusion of cases where certain investigations were not clinically indicated. These factors may limit the generalizability of the findings. Future research should involve multicenter studies to validate these observations across diverse settings and explore the impact of interventions such as standardized templates, peer-review systems, and AI-based solutions on improving documentation practices.

CONCLUSIONS

This study demonstrates that the quality and completeness of SOAP-based clinical documentation, particularly the Objective component, significantly influence the quality of treatment planning in excisional biopsy cases. While the Subjective and Assessment sections showed excellent adherence, notable gaps were identified in the Objective and follow-up documentation. The introduction of a structured DQS enabled objective auditing and revealed a moderate, statistically significant correlation with expert-rated treatment plan quality. These findings underscore the importance of structured documentation not only as a communication tool but also as a determinant of clinical decision-making. Strengthening documentation practices through standardized templates, EHRs, regular audits, and clinician training can enhance patient outcomes, institutional efficiency, and medico-legal compliance. Continued efforts in this direction are essential to elevate documentation standards and promote evidence-based clinical care.