SOAP Note: How to maintain respect in conveying concern for your patients' weight

Written By: Adam Reid, MD, FACS, Assistant Professor, Surgery, Bariatric Surgeon

Happy New Year! 2020 is here and our Earth has initiated another journey around the Sun! Many of us may interpret the start of a new year as an opportunity to reflect, give thanks, dream, resolve conflict, set goals, and rejuvenate. Traditionally, resolutions have become part of our entrance into a new year.  Resolutions are defined as “firm decisions to do or not do something”. According to Statista, four of the top five popular New Year’s resolutions for 2020 involve improving one’s health. These include eat healthier, be more active, improve mental well-being, and lose weight.   

As health care providers, we have the opportunity to help our patients maintain the health-improving resolutions they made. Our patients may present to clinic receptive to suggestions to help them achieve improved health during this time of year and might be open to discussions related to diet, exercise, mental well-being and even weight loss. Having a conversation related to weight loss is not easy, regardless of the time of year. The subject is a sensitive one, the disease is complex and treatment requires participation from both patient and provider. Time constraints of a busy practice alone may inhibit our ability to address the issue and for some, dialogue regarding body weight is rare or nonexistent even though the benefits of maintaining a healthy BMI are many. Approaching the weight-loss conversation in an organized fashion may prove effective.

Initiation of the conversation requires a thoughtful approach. Opening statements may include “How do you feel about your weight?” or “Could we talk about your weight today?” Some patients may be offended by “obese” or “obesity” and using phrases such as “high BMI” or “excess weight” might be more appropriate during the initial phases of the conversation. Maintaining respect and conveying concern as opposed to judgement are vital and consolidating the remainder of the discussion into a “SOAP note” format ensures acquisition of important information and formation of a treatment plan.

Subjective:

Allow patients to recall the history of their weight, attempts to lose, triumphs, failures, factors associated with recidivism, current diet, and activity level. Address patient-specific issues associated with elevated BMI, and future risks. Help patients consider reasons to improve BMI and specific barriers preventing weight loss.

Objective:

Data can be a powerful motivator for some patients. For example, if a patient presents with a systolic BP of 187, we communicate the abnormality and most patients will agree to the suggested treatment for hypertension. Vital signs are obtained at most office visits along with height and weight to calculate BMI. This piece of objective data is very important and BMI is used to classify the patient as normal, overweight, obese, or morbidly obese. Comorbidity review is important and potential improvement or resolution of a comorbidity may provide sufficient motivation for change.

Assessment:

At this point, applying a diagnosis is appropriate and declaring a patient overweight, obese, or morbidly obese may help communicate the significance of high BMI or excess weight. Evaluate potential for benefit regarding comorbidities and assess the insight that a patient has regarding their diagnosis and motivation level for change.  

Plan:

Reviewing treatment options for obesity will help patients and providers develop a management plan. Initial treatment for obesity includes a diet and exercise regimen. Referral to an obesity management program or pharmacotherapy may also prove beneficial for select patients. Weight loss surgery is considered in patients with BMI >40 or BMI >35 with an obesity-related comorbidity. Surgical candidates are carefully selected and have experienced failure of less invasive weight-loss methods.

Overall, a weight loss conversation with a patient may result in significant improvement in health and this discussion may be initiated by either the patient or provider. When discussing obesity, it is important to gather subjective information, evaluate objective data, achieve a reasonable assessment and apply an appropriate plan for weight loss. This discussion may happen at any time, and for some patients that time is now.