I have advocated before for putting a visit synopsis at the beginning of each visit note. I have called that the aSOAP note. I think that works immensely better than APSO notes that only rearrange the order of the elements. The reason I say that is that in today’s EMR notes, it’s too darn hard to find THE STORY. If a note is half a dozen pages or scrolls long, why would I want the medication changes and the reason why they were made at opposite ends of the note? The order means less than the distance between them in my opinion.
The way I approach reading a note is with the two questions “What happened in the last visit?” and “Why was that the clinical decision?” In more and more of my office notes I answer these two questions for future readers, which would include me, in temporal, typographical and spatial connection with each other, right on top.
Let’s face it, how often would it be more useful to try to scan a lengthy Review of Systems and a Comprehensive Exam to find the pertinent positives than to read in the top paragraph that the patient who was placed on a potassium sparing diuretic two months ago and kept rescheduling their followup appointment is now hypotensive and nauseous with an unusually pale complexion and putting out less than normal amounts of urine. Consequently we stopped the medication, sent the patient for STAT labs or to the ER. Seriously, I don’t need to read anything more in that office note: You and I both know this person is in acute kidney failure, caused by the spironolactone. DONT WASTE MY TIME AS A FUTURE READER by mixing those crucial elements with other, less pertinent information. Put it in there, away from the story in case somebody needs to check if we screened for depression or smoking status, but those are filler materials and side plots in this riveting STORY of iatrogenicity.
I admit that in today’s healthcare environment, the office note serves many “stakeholders” (I’m not sure I like that word…), but since I am the clinician who sees the patient, makes treatment plans and then has to follow up on what parts of the treatment plan worked and what parts didn’t, I can’t accomplish anything without the thread of the chain of events I am ending up calling THE STORY. It belongs to the patient, but I’m the one that needs it, desperately sometimes, as even small nuances in the narrative of a life or a disease can change my assessment and the trajectory of care I provide.
And, here’s a confession, if I don’t have time to finish my note in real time, or if (ahem) I’m catching up on a backlog of chart notes, it’s the “a for abstract” segment I focus on; the number of “bullets” and 99213 versus 99214 is not my priority when I’m in survival mode (mine AND possibly the patient’s).
So I am again making the case for a narrative abstract at the top of each office note, an executive summary if you will, just like the world of academic journals has decided to present complex information.
If it’s good enough for The New England Journal of Medicine, it should be good enough for this Country Doctor.
A Country Doctor Writes: 
Hans
You just explained my daily struggle in an eloquent manner
I’ve often wondered why we can’t do our SOAP
Notes and the way we were trained
And then let nurses worry about the data they need to collect to meet the guidelines for insurance companies and government agencies ( which is why I got so so frustrated with medicine !!!)
As docs we know what we need to see in the note and we know what is the needed fluff
I was much more efficient with a paper chart
Or a dictation device
Talk soon
Kelley Guthrie MD
Our system is so messed up and “bass-ackward” that we now spend more time on documentation than we spend with patients. I like your proposed solution. When I did hospital consults in New Mexico during a 6-month locum this year, I would initially leave just such a written synopsis in the EMR, and then would “cut and paste” this into the designated spot in the multi-page standard consult format as I labored in front of the computer at the end of the day.
As a nurse visiting your blog, I agree. We sometimes spend literal HOURS pouring through notes trying to get a complete clinical picture of, sometimes up to 8 patients (tele) in a 12 hour shift. I could work so much more efficiently if I didn’t have to scan through a complete medication lists and all test results from the current visit 27 different times.
At one facility I worked, there was a clinical nurse supervisor who had assigned herself the task of summarizing the patients condition (as they arrived to the unit) in 1-3 paragraphs and photocopied this to the front of each chart. It was so immensely helpful.
Comprehensiveness is a myth.