Home Forums Discussions General Discussion APSO vs SOAP

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.

Another note....

Bert,
I agree that having learned to create and read "SOAP", that there is little reason to make notes "APSO". In fact the ONLY reason is all of the excessive verbiage jammed into notes now, which makes it so hard to FIND the assessment and plan.
Which brings up an interesting feature of AC that is one of its strong points; one that could be made even stronger, with just a little coding, if Chris would agree. (Maybe that could be MY holiday present). With that teaser, I plan to come back with a longer post explaining what I mean.

Meanwhile, maybe your post here is a 10th anniversary shout-out to my first post on the board, in September, 2009. That post asked a basic question: how to create a SOAP note in AC. In retrospect, the answers are interesting: Bert, you immediately, and briefly said "you can't". In fact, as typical of the board at that time, about 10 people chimed in to suggest possible work-arounds. Travis, a general surgeon who long ago left the board, gave the best suggestion. In fact, you CAN easily create a SOAP note in AC (at least, when you do the note) but NO ONE KNEW how to do it! That says something about AC....

https://acusersforum.com/ub/ubbthreads.php/topics/16301/a-basic-question-soap-notes#Post16301

Happy 10th anniversary. I wonder with the many huge EMR programs like eClinicalWorks or eMDs or NextGen, if they have a board and many post. I don't think AC always realizes (given some of the issues over positive and negative feedback) how the consistent posters to the board have helped shape AC. And, while the shape may be different than what we want, we do move toward a better shape because of Chris C. For better or worse, Chris has been the one that came in and began to really develop the program forward.

Anyway, I spent 10 minutes reading that link. Wow, were we nice to each other then. Hell, I was even nice. I guess I forgot but I do see how the SOAP note can be done now thanks to Travis. When AC wasn't as developed, workarounds were much more prevalent.

Bringing up the workaround stated, I wish there were a way to leave out things as well. Maybe someone can enlighten me. I haven't tried hard, but I still have ROs, PMH, unused VSS fields, and Goals, Health Concerns and Instructions listed even if I don't use them. The respiratory rate, pmh, instructions, etc. stick out like a sore thumb if you don't use them. Seems like if a field isn't used, it shouldn't be labeled.

While we are at it, it did make sense to have someone or the doctor add, "updated by so and so on such and such a date." But, then it stays there forever.

While we are on it, I still try very hard to leave the chief complaint empty and write it in the HPI, and after the assessment, I typed the diagnoses in caps in the CC field. Once again, fever and fatigue or just fever and irritability means nothing in the past encounters, while LYME DISEASE and RIGHT OTITIS MEDIA are much more helpful.

I suppose on Leslie's point having the PMH and FH addressed by the specialist does show they looked at that, but as Jon says, we don't need that on every note.

The note is way too cluttered, and the old-fashioned dictated SOAP note, while likely not as helpful for CPT, E & M and thoroughness due to forced fields, is so clean and so helpful. ED notes were great that way.

I don't find that the AC's EMR slows me down, but I can see how an ED doctors would think the notes they use do. Now we get these APSO novels from H & Ps, discharge summaries, consult notes, ED notes. Most PCPs hate them.

I love the consultant that writes, I know you know the history but please allow me to document it for my record. Then, they write a
history which is five times better than mine.

We have a neurologist here, whose basic note is:

S: Patient returns for f/u seizures. Keppra working fairly well. Has had two seizures since last month.

O: Still looks like the same patient from last month. No fevers, weight and height ____________

A: Better. Seizures still on monotherapy.

P: Will add second anti-seizure med and get EEG in two weeks.

Thank you for allowing me to participate in this young man's care. (Jon are you guys really happy to participate)

_____________________________________

There was a time, not sure if they are still doing it, that the ED docs were forced to write this differential diagnosis. A kid would come in for fever and listlessness (our work for the parent's lethargy). They would list I considered viral syndrome, sinus infection, meningitis....

Well, it was good to list them, but I always felt that stating you considered meningitis, but you did nothing to rule it out: CBC, spinal tap, etc., was a lawsuit in the making.

Larry Weed's "Problem Oriented Medical Record" was a huge big deal at UofO Medical School in 1967/68 and for a few years afterwards. The "old" clinical staff was appalled by the new way of organizing medical thinking and charting. They got used to it after a while.

The original Weed system was pretty cumbersome and complicated for anyone with more than a few problems (like virtually everyone at the medical school chronic disease clinics) -- especially when they saw multiple students and attendings, each of whom had a different take on what the "Weed System" really was.

It sort of collapsed into the various versions of the SOAP format which actually does work pretty well for most narrative-style notes.

I don't see that anything improves by starting the note with the conclusion of "medical decision-making" (as opposed to starting with why the patient went to the doctor in the first place) , then piling on boiler-plate garbage to presumably bolster that conclusion -- it's backwards, and the only advantage is that if it is done correctly you don't have to try to read a 15 page note if you are seeing a patient in followup from an ER visit for a cold.