APSO needs to replace SOAP in EMRs

Electronic medical records (EMRs) have a bad reputation among many physicians for generating progress notes that are so verbose and filled with standard phrases that they are nearly useless to other physicians, and even to the physician who produced the note in the first place.  This is in part because rather than engineering the EMR to produce a note intentionally efficient and effective for users looking at the note on a computer monitor, many EMR users choose to create a record familiar to them from years of use of paper charts.  A note documenting a patient visit really serves only 3 purposes.  First it is a clinical note documenting the patient’s history, findings on exam, and the assessment and plan of care.  This is ideally efficient to generate, easy to review, and have the information needed in future visits in an easy to see and understand format. Secondly the note is a legal document, providing documentation of care and advice provided, and needs to be useful in case of a legal challenge.  Third it needs to document the care done to justify billing and assure payment by third party payers.  A good note does all of these things.  In many EMR systems the last two are done well, but the clinical usefulness of the note is very poor.

Most EMR notes do a great job of documentation to assure payment. The ability to easily enter the information needed to justify a level of billing is sometimes too easy, and EMR users have been criticized for overbilling as a result.  From a physician’s point of view, being easily able to enter the information required by payers without doing a long and costly dictation is a big plus of EMRs.

EMRs also can easily make a document that does a good job of producing a document that can stand up to legal scrutiny.  Although there is little data to prove it, some experts believe use of an EMR can reduce liability.

When a physician reviews a prior progress note, the information they usually want to see the assessment and plan.  Much less often they need to know the details of the patient’s history, examination, review of systems, etc.    In a paper chart it is just a movement of the eyes to find the desired part of the note, and it makes little difference whether the needed information is on the first few lines, or at the end of the note.  The traditional progress note format is the SOAP note: Subjective history first, Objective information like vital signs, physical exam and test results next, Assessment including the diagnosis and documentation of the thought process and decision making third, and the Plan of treatment last.  This reads in a logical fashion, and has become the standard format in most paper patient charts.  In an EMR note reviewed on a computer monitor, the traditional SOAP note simply does not work.  The history of present illness, past medical history, family, and social history, and review of systems, and physical exam more than take up the available space on a monitor.  To see the needed information, the assessment and plan, requires scrolling to areas hidden on first glance. This is exacerbated by the ease of documenting repeated information like past medical history and family history, which might be stated very briefly in a dictated note, but are often included in much more detail in EMR notes.  The information is also usually in a format that requires more screen space than a dictated note.  In EMR templates that simply try to reproduce the end product of a dictated note, i.e. a SOAP note, the product is a note where all of the key information is a long scroll away.

Consultants have known for years that their referring physicians do not want to look through the entire history and physical exam documentation to get to the assessment and plan. Most consultants make notes to their referring physicians with the Impression and Plan/Recommendations at the top.  This allows the referring physician to quickly see the key information they need, and then choose to review what other information they need.  As physicians making notes primarily for our own and our associate’s future use, we need to give ourselves this same ability.

Simply making an APSO note instead of a SOAP note, i.e. putting the Assessment and Plan first, and the Subjective history and Objective information later can make reviewing notes much more efficient.  This simple change can be done easily in most EMRs, and just requires thinking about the different work process using a computer monitor to look at information.

We need to modify our work processes to make our technology work for us, not try use the technology to electronically reproduce previous workflows.

Ed Pullen, MD, is a board certified family physician practicing in Puyallup, WA. Dr. Pullen shares his viewpoints on medical news and policy from a primary care physician’s perspective  at his blog, DrPullen.com.

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15 replies »

  1. These additions make no sense to me. All fits well enough into the original SOAP model.

  2. Added to delicious and my blog. Thanks for the info.
    Yes good news and will try to check if i can use this

  3. Reinforcing my Point?
    Just over half of pediatricians responding to an anonymous survey acknowledged making at least one diagnostic error a month, and just under half said that at least once a year they made errors that harmed patients.
    Other key findings from the survey included: When asked to identify the reasons for diagnostic process errors, about half of the doctors (48%) cited a lack of information of the “patient’s medical history or failure to review medical charts” …!
    Be it papr or electrons, colleagues please … read the damn chart.
    Dr. David E. Marcinko MBA

  4. Ed and TCHB,
    A well crafted post. Now, for a slightly different POV.
    SOAP[IER] eMRs … Beware the Alphabet Soup Switcher-Roo
    Now more than ever, inadequately documented medical charts can mean civil and criminal liability to the sloppy and/or unwary practitioner.
    Medical records were previously used to aid in the quality of medical care. Today, they are also the basis for payment for services, not as a record or reflection of the care that was actually provided, but as a separate justification for billing.
    Medical Records not a Reflection of Reality – Are Reality Itself
    Link: http://medicalexecutivepost.com/2010/05/17/soapier-emrs-%e2%80%a6-beware-the-alphabet-soup-switcher-roo/
    Dr. David E. Marcinko, MBA
    Hope R. Hetico; RN, MHA
    Chief and Managing Editor

  5. Our facility is trying to standardize report format/content. I read a couple of articles sometime back regarding universal/state guidelines for such.
    There was another article about formatting specifically for EMR (not pop-up menu templates but rather narrative text). Some of the topics discussed were (in the context of increased amount of documentation now required) difficulty reading from a computer screen, the need for report consistency, and some changes in formatting to enable the reader to quickly find info (i.e., indenting and bulleted/numbered lists when possible).
    Naturally, I cannot now find these. Any suggestions?

  6. I’d go one step further: if you are trying to solve a scrolling problem, you are still in the paper metaphor. It’s not what to put in what linear order; it’s what GUI presents the parts to the eyes in the right order. These are two different questions.

  7. As long as the emphasis is on immediate profit (billing, liability protection), these systems will continue to puzzle physicians. Y’all are too close to this.

  8. Too much billing provoked gibberish on the record, interfering with the facts of the case.

  9. This is a very astute observation. I know that when I was using the DOD AHLTA system when I looked at previous notes, I would immediately scroll to the diagnosis, assessment and plan. Then I would examine the patient based on their history (a focused examn), and then return to look at previous specifics.

  10. The traditional SOAP format of medical charting, noted above, was developed by Dr. Lawrence Weed in 1968. More formally, it is known as the Problem Orientated Medical Record [POMR]. However, the concept was updated about 20 years ago by adding the extension SOAP[IER]:
    I = Intervention
    E = Evaluation
    R = Revision
    Dr. David Edward Marcinko; MBA, CPHQ
    Atlanta, GA

  11. Nice post. I’ll add two thoughts.
    First: far too much of eHR design, deployment and use is aimed at documentation for billing and liability reasons, rather than to document the salient medical data and reasoning process that led to selection of a particular assessment and plan.
    Second: because almost all major eHRs are built using 10+ year old coding and by people looking at paper documentation (rather than ideal clinical decision making), the potential for improvement is frequently missed. Imagine, for example, a note that said ‘ROS is negative except for X, Y, Z (naming the pertinent positive and negative items) with ‘ROS’ a link that brings up a box with all the ROS items asked and the response. The PE would also lend itselft to this aproach.

  12. Very thoughtful post. It exemplifies how big the little things really are and how relatively easy it is to provide value.
    I have heard this request from numerous physicians and the solution is incredibly simple for most EHR vendors. All it takes is to provide a place for users to order the various parts of the Note. Most already do that for custom letters anyway.
    It is important to let users customize because there are docs that would prefer to prepend med list & problem list to the APSO, while others would want only the HPI on top and the other histories on the bottom or even totally collapsed (to be viewed only on demand).
    The more choices, the better.