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 complement to a more consistent use of this kind of structured data entry.
The abstract is not the same as putting the assessment and plan up top. It mixes all the elements of the progress note in concise form: Past history, new symptoms, Objective findings, immediate and next-step plans. It reveals how the clinician thinks.
I believe the slight amount of time it takes to Dragon or Siri (are those verbs yet?) an “abstract” is regained in multiples every time we later have to look back in our own or a colleague’s progress note.
Here are some imaginary examples:
“Former smoker with 3 week history of cough, recent weight loss. Azithromycin, inhaler, lab, x-ray when available and FU 2 weeks, CT prn at Cityside if creatinine still ok.”
“DM, HBP, migraine, psoriasis fu, all stable. Foot exam wnl. Offered Shingrix and colonoscopy, wants to wait. Refill all meds. FU 3 mo.”
How many more seconds would we need to spend on reading the rest of such notes? Probably zero.
Time saved. Move on. Here’s my marketing slogan: aSOAP makes ASAP!
(For those of you who weren’t there…this is what entire office notes used to look like. I’m proposing that the future lies in the past.)
A Country Doctor Writes: 
Some of my favored and favorite consultants did this, both inpatient and outpatient. The advantage, of course, was that the ‘small a’ or executive summary was efficient. The disadvantage was that it made it too easy to skip reading the full note and missing important details and nuances. Two advantages you do not mention is that doing a summary is a good way to force the clinician to distill the note in their own head, and (if properly done) can be a very helpful summary for the patient or caregiver.
We skip reading the full note anyway as it is…
“(For those of you who weren’t there…this is what entire office notes used to look like. I’m proposing that the future lies in the past.)”
Could not find link to click on for this…..is it missing?
What I meant was that the brief vignettes above where the entire office notes before soap notes were invented.