A long time ago, a guy named Larry Weed developed the
POMR (Problem Oriented Medical Record) and it's offspring, the SOAP note or (Subjective, Objective, Assessment and Plan). All designed so that there was a standard for everyone to use that made sense.
I have found an excellent article about it written by a medical student at Texas Tech. Ironically, it brings up points that I was going to make anyway.
There are two types of notes I encounter daily. Those coming from the ED and sometimes records, and those coming from a consultant. Putting aside the sheer volume of information, which I will address later; The APSO format, for me anyway, is extremely confusing. All the ED notes we get now, are APSO format.
Assessment
Plan
Subjective
Objective
The assessment is now written as an MDM (Medical Decision Making). So, they somehow cover all the possibilities in the first paragraph. This is generally, two to three times longer than the HPI, which is much further down the page. The idea, I suppose, it to document the most important part of the note (the assessment and plan) first.
I don’t know. I find this annoying as I see an ED note and the diagnoses at the very top. I am just hardwired to read through the flow of the history, then the exam, then the studies, then the A/P. There is something about my going through the process myself as I arrive at a differential.
Throw into this the new format of putting all the PMH, PSH, FH, Social History on the side along with every lab with the time and date after every value, and it gets more convoluted.
Of course, there is then the added CYA, Meaningless Use, and all the other Acronyms. The note makes sure the coding fits the encounter. The drugs are usually listed three or four times. Then there is the list of questions (about 30) with Not on file 29 times mainly because a three-week-old doesn’t smoke pot.
While I have been guilty of this myself and now NEVER do it, is the templated physical exam. The patient is there for conjunctivitis, and there are 12 PE bullets including a full neuro exam. I check, and they are the same on every note.
Finally, there is the “A 10-point review of systems was asked, and they are all negative except for those in the HPI.” (And where can I find the HPI).
It is so difficult to read that I find myself not reading them at all.
Now the consultant version, which I have seen since medical student days makes sense. When you refer to a consultant, you basically know the S & the O. You have seen the patient. You just don’t know what the A & P is. So, for the consultant note, the Subjective and Objective is usually put in as “just for my record, I will include the S & O. But, being able to look at a GI consult note which states, this and that, and it seems the patient has IBD. And, my plan is to start Remicade after steroids, and see the patient back in four weeks is all we need. The nice thing about the included S & O, is given the experience of the consultant and the “added time” they have that part is usually coherent and much better than what I have and is in one place so that note can be sent to the next doctor.
There is much to be said to have a note that is mandated by policies, as generally nothing is missed. But I do miss the old dictations from the ED where there were four paragraphs, which flowed from the provider to the page. And, you knew that the exam was exactly what he or she found. In the last note I read, it had:
Temp 98.7, Tmin 98.6, Tmax 98.7. Where will it stop?
I do want to say this isn't just my bashing of today's medical record and how it is has evolved and hurt medicine. I am just wondering what those think of this format for non-consultants and the risk (too much info) vs benefit (EVERYTHING) documented.
I do sometimes wish I could be more thorough. And, I do not want to offend any consultant or ED doctor. But, I wonder how many patients an ED doctor typically sees in a day. And, now with the Transciption Medical Fluency software where the caveat is there could be typos, etc. and it is not read, who knows. I know I could never get all this info into every note. And, this is the same note they use for a black fly bite as HSP.
My guess is that soon, they will be required to list at least three Double-blinded, placebo controlled studies in the note to show where they derived their diagnosis of acute otitis media.
