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.Continue reading…