The Perfect Office Note? SOAP, APSO or aSOAP?

By HANS DUVEFELT MD  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 aSOAP; abstract, 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 complem...
Source: The Health Care Blog - Category: Consumer Health News Authors: Tags: Physicians EMR Hans Duvefelt Patient Notes Source Type: blogs