Physicians

The Perfect Office Note? SOAP, APSO or aSOAP?

By HANS DUVEFELT MD Dr. Hans Duvefelt, A Country Doctor Writes, physician burnout

I’ve been toying with this dilemma for a while: SOAP notes (Subjective, Objective, Assessment, Plan) are too long; APSO just jumbles the order, but the core items are still too far apart, with too much fluff in between. We need something better – aSOAP!

Electronic medical record notes are simply way too cumbersome, no matter in what order the segments are displayed, to be of much use if we quickly want to check what happened in the last few office visits before entering the exam room.

It is time we do something different, and I believe the solution is under our noses every day, at least if we read the medical journals:

I can be aware of what’s going on in the medical literature without reading every article. How? Think about it…

A patient note, like a scientific article, should not present the information in reversed or scrambled order. It should follow logic. But, just like any long research paper worth considering, we should simply create an ABSTRACT and put it up top. Enter the aSOAPabstract, Subjective, Objective, Assessment, Plan.

In many ways, EMR office notes are created so automatically and by more than one individual, that the author’s (clinician’s) logic can be elusive when you read the note. There are also click boxes that could be used to document the “story” but which many of us avoid because they don’t offer enough variety to distinguish one scenario from another. A free-form “abstract” can be a perfect complement to a more consistent use of this kind of structured data entry.

The abstract is not the same as putting the assessment and plan up top. It mixes all the elements of the progress note in concise form: Past history, new symptoms, Objective findings, immediate and next-step plans. It reveals how the clinician thinks.

I believe the slight amount of time it takes to Dragon or Siri (are those verbs yet?) an “abstract” is regained in multiples every time we later have to look back in our own or a colleague’s progress note.

Here are some imaginary examples:

“Former smoker with 3 week history of cough, recent weight loss. Azithromycin, inhaler, lab, x-ray when available and FU 2 weeks, CT prn at Cityside if creatinine still ok.”

“DM, HBP, migraine, psoriasis fu, all stable. Foot exam wnl. Offered Shingrix and colonoscopy, wants to wait. Refill all meds. FU 3 mo.”

How many more seconds would we need to spend on reading the rest of such notes? Probably zero.

Time saved. Move on. Here’s my marketing slogan: aSOAP makes ASAP!

(For those of you who weren’t there…this is what entire office notes used to look like. I’m proposing that the future lies in the past.)

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

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Pesto SauceBobbyGvegasLeoHolmMD Recent comment authors
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LeoHolmMD
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LeoHolmMD

The patient chart has needed revolution for a long time now. Too many obstructionists like the AMA, CMS, MGMA and other groups who think a complete review of systems means anything other than trolling the patient. I guess they need a legacy bridge to guard to keep themselves relevant. We need a patient centered form of documentation with the concision that will serve doctors and patients alike. Unfortunately, there do not seem to be any “disruptive innovators” in this realm. This has been exacerbated by the data mongers who want every morsel of information as structured data…even though they don’t… Read more »

BobbyGvegas
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BobbyGvegas

Great comment. Cited and linked at my KHIT.org

Pesto Sauce
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Pesto Sauce

The note isn’t for medical assessment nor recording key facts any longer. It’s a coding/billing document. Our wonderful art, the SOAP note, is only alive in the records of those patients & docs who refused EMR and are direct pay or out of the insurance quagmire.