SETTING THE STAGE: STRATEGY OF CARE NOTES
The Strategy of Care (SOC) note in Epic is a powerful tool designed to address critical concerns that impact patient care in the acute setting while supporting continuity of care after discharge. By standardizing documentation, SOC notes help reduce provider variability in common areas such as pain management, patient nonadherence, or refusal of essential diagnostics and treatments. They also ensure consistency in goals of care when providers transition on and off service, creating a unified approach across the care team.
Beyond improving clinical alignment, SOC notes serve an important role in establishing or re-establishing expectations of care for patients and families, aligning these expectations with recognized standards of medical practice. It is essential to note that SOC notes are not intended as contracts or binding agreements; rather, they are a communication tool that influences patient behavior without attempting to control it. In many cases, SOC notes complement behavior contracts, working together to reinforce shared goals and foster collaboration between patients, families, and providers.
At Mercy, SOC notes have proven especially valuable in ethics consultations for complex care patients. Mercy Joplin and Mercy Springfield frequently collaborate on ethics consultations due to internal transfers for high level of care and the close geographical proximity of both hospitals. We discovered that utilizing SOC notes supports a unified approach across the health system, reinforcing expectations set by providers, and ensuring continuity of care for patients and families navigating challenging decisions.
PROCESS AND REASONS FOR SOC
Establishing a Strategy of Care (SOC) note in Epic is a straightforward yet impactful process designed to ensure visibility and alignment across the care team. Once a SOC note is created, a prominent red banner appears at the top of the patient's chart, displaying essential information immediately. This visual cue alerts all providers to the presence of a SOC note, ensuring that critical context and expectations are immediately accessible during patient encounters. (See the example below.)
The decision to implement a SOC note typically arises in situations where patient care is at risk due to behavioral, ethical, or clinical complexities. Common reasons include:
- Over-exercise of patient or family autonomy or a misapplication of respect for autonomy, resulting in medically inappropriate care requests or complex goals of care.
- Inappropriate patient behavior/violence against staff or nonadherence to indicated care or diagnostics, which can lead to missed clinical indicators and acute declines.
- Repeated refusal of indicated care, which may be understood as a revocation of the consent-to-treat agreement and, in some cases, can serve as an indication for discharge.
- Targeted clinical domains with complex care such as behavioral health or pain management.
By documenting these concerns in a SOC note, the care team creates a unified, transparent approach that reinforces standards of medical practice while maintaining ethical integrity. This strategy not only mitigates risk but also supports continuity of care across transitions, ensuring that expectations remain clear for both patients and providers.
BEST PRACTICES FOR UTILIZATION
The inclusion of a Strategy of Care (SOC) note in a patient's chart can unintentionally introduce bias among providers and caregivers who may not fully understand the circumstances that led to its creation. Without a consistent approach, these notes risk misinterpretation and confusion about expectations.
We identified two critical challenges:
- Inconsistent language and usage can lead to ambiguity and undermine trust.
- Outdated strategies raise questions about when and how revisions or inactivation should occur.
The overarching goal of a Strategy of Care is to restore right relationships between patients, providers, and caregivers. It aims to foster understanding, strengthen trust, and promote quality care, patient safety, and improved health outcomes.
Step 1: Developing SOC notes
Creating a Strategy of Care is a collaborative process involving clinical and leadership representatives. The intent is to reduce provider variability, which can send conflicting messages or inadvertently enable manipulation.
Key principles for development:
- Align with Patient Rights and Responsibilities, while recognizing that SOC is not a contract—it focuses on behaviors providers and caregivers can control.
- Ensure each element is clinically and ethically sound, achievable, and supported by administrative and clinical leadership.
- Obtain consensus and leadership approval before implementation in the EHR.
Teams should also determine:
- Whether the strategy is continuous or time limited.
- Who is responsible for scheduled reviews and updates.
- If applicable, use EHR features to set expiration dates for time-bound strategies (e.g., an 8-week antibiotic
- course or a 6-month postoperative period).
Step 2: Communicating and Implementing SOCs
Transparency and honesty are essential when discussing SOC with patients—except in rare cases where safety concerns justify withholding details.
Who should lead the conversation?
The designated communicator must remain calm under pressure and assert authority respectfully. This dialogue should:
- Acknowledge any provider or caregiver contributions to misunderstandings.
- Recognize the stress and loss of control patients may feel during hospitalization.
- Reinforce norms of patient safety and quality care.
- Reassure patients that expectations are consistent with those for all patients, not punitive or unique.
This structured approach ensures SOC notes serve their intended purpose: clarity, consistency, and compassion in care delivery.
AMANDA ALTOBELL, MTS, PH.D., HEC-C
Director, Ethics
Mercy Hospital Springfield
TRACY BORGMEYER, MA, LCSW, HEC-C
Director, Ethics
Mercy Hospital Joplin
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