Physicians rethinking the progress note

Doctor entering notes on a tabletA new form of physician progress notes seems to be taking hold.

Physicians assess 'SOAP' vs. 'APSO'

The "SOAP" -- subjective, objective, assessment, plan -- format has been in common use for decades as a way of organizing physician progress notes in medical records, but it was created during a different era, when most everything was written on paper. In the age of electronic health records, some are rethinking the order of presenting information, electing to go with the latter two elements first in what's being called an "APSO note."

An early adopter of the APSO format, C.T. Lin, MD, CMIO of Aurora, Colo.-based University of Colorado Health, explains that physicians often flip right to the assessment page of paper charts to see what previous visits or referring doctors may have found. By this reasoning, it makes more sense to put the assessment and plan first in an electronic note, according to Lin.

Lin was lead author of a paper published in JAMA Internal Medicine in January 2013 that found that SOAP "translates poorly from paper medical charts to the EHR" because it takes a lot of clicking and scrolling to find the assessment and plan. The article detailed a 2010 study at 13 University of Colorado Health ambulatory clinics that produced mostly positive results from an APSO trial.

[See also: 'Note bloat' putting patients at risk.]

For the study, eight of the clinics — six in primary care and two specialty clinics — mandated APSO notes, and the rest made it voluntary. All providers in the locations where it was mandatory and slightly more than half in the voluntary clinics did adopt the APSO format within the two months, according to the report.

The researchers, led by Lin, found that 73 percent of participants were "satisfied" or "very satisfied" with the APSO format when writing progress notes, and 82 percent said the same about reading APSO notes. A full 75 percent said they "preferred" or "strongly preferred" reading APSO notes, compared to just 8 percent who said SOAP was better.

Another 2010 study, conducted at Lucile Packard Children's Hospital in, Palo Alto, Calif., and reported in the journal Applied Clinical Informatics in May 2012, found that APSO "made reviewing of the notes easier."

Since then, University of Colorado Health has migrated to an Epic Systems EHR, standardizing notes in APSO style in the process. "During the switch, I really took advantage of a burning platform," says Lin, who reported encountering plenty of resistance during earlier efforts to mandate APSO across 40 clinics.

Today, more than 90 percent of physicians affiliated with the health system are using the APSO format for inpatient and outpatient progress notes. "Anecdotally, I have heard fewer complaints," Lin says.

[See also: Brainstorming About the Future of Clinical Documentation.]

It's unclear how many organizations have switched to APSO, but Lin says he has presented about the new format at Epic's annual users' meeting several times. The response was "overwhelmingly positive" among physician leaders, though not unanimous, he reports. "But they don't know if they'll make it work in their own organizations."

He says Epic's own physicians are recommending it as a best practice, and the latest builds of Epic's software have made it easier to get to the assessment and plan.

Still, there are doubters.

A new article in the journal Applied Clinical Informatics, from researchers at Baystate Health in Springfield, Mass., tracked the eye movement of 10 hospitalists as they read EHR notes to see where the doctors focused their attention. The hospitalists spend the most time viewing "impression and plan" sections, paying less heed to elements such as medication lists, vital signs and laboratory resultsthe subjective and objective.

"Optimizing the design of electronic notes may include rethinking the amount and format of imported patient data as this data appears to largely be ignored," this study concludes.

And then there is the creator of the SOAP note, the venerable Lawrence L. Weed, MD, who still believes SOAP is superior. "Never put your opinion before the facts," Weed tells Healthcare IT News. He said it's easy to flip to the assessment and plan with a SOAP note. "That's the typical habit," Weed says, looking for shortcuts.

"The supposed advantage of the APSO alternative -- that it begins with the physician's assessment rather than data -- is actually a failing. This sequence tends to make the note provider-centered rather than patient-centered, and judgment-based rather than evidence-based," Weed and son Lincoln, an attorney in Oakton, Va., say in a follow-up e-mail.

"In contrast, beginning the progress note with data disciplines the provider's assessment. The provider must think in terms of specific data, specific problems on the problem list to which the data relate, and the interrelationship of each problem to the other problems on the list. Moreover, it's important to begin the progress note with subjective (symptomatic) data from the patient rather than so-called 'objective' data," they add.

Told about Weed's comments, Lin says, "You're really skipping the logical reasoning." He says that the subjective and objective parts are key in cases where there is "diagnostic uncertainty," but notes that those components are still there for reference even in the APSO format.

"It's not a perfect solution," Lin says, "but this is a quick win."