Should the SOAP note be changed?


Our hospital system’s IT department has recently encouraged us all to change our default encounter note template from the traditional “SOAP” format to the “APSO” format.

For those not familiar with those acronyms:

S: subjective — the patient’s story
O: objective — physical exam, labs, other data
A: assessment — the identified issues/diagnoses
P: plan — details of how to address issues/diagnoses in the assessment

The argument in favor of APSO, putting the assessment and plan first, is that no one reads the subjective and objective. Readers just scroll through the S and O to get to the A and P, so why not make everyone’s lives more efficient by putting the A and P first? From the hospital to our outpatient office, our system is encouraging us to create patient encounter notes in the APSO format.

As residency faculty, I review a lot of resident notes in the process of supervising them, and despite this switch in the last few months, I can’t seem to adjust to reading APSO notes. Maybe my perspective is different since I actually have to read the S and O as part of my supervisory responsibilities, but jumping straight to the assessment and plan just feels jarring and out of order.

Documenting those subjective and objective sections can be challenging within the electronic health record (EHR). It’s faster to click boxes or use a template than to type out the unique aspects of a patient’s story and/or exam. Don’t get me wrong: Templates and click boxes increase efficiency in documenting simple yes/no responses and normal findings. Reading a subjective and objective that’s all click boxes and templates, however, doesn’t provide a compelling story. (It can even invite wondering whether everything clicked and templated was actually asked and done.) No wonder busy physicians would rather skip to the end.

I just can’t get behind starting at the end with this APSO format. I like opening with the patient’s story and the directionality of proceeding from that through the exam to the assessment and plan. The patient’s individual story is valuable, both in providing key details to successful care and validating the humanity of each patient. I free text a significant portion of my documented subjective*, and I add any pertinent unique details to the exam template in our EHR.

Starting with the assessment and plan disincentivizes reading those stories. I worry that future physicians, who may learn APSO as the norm, may not appreciate the value of a well-composed subjective and a thoughtful physical exam.

I’m sticking with SOAP.

* In the room, as the patient shares it; and, yes, patients are quite accepting of that practice.

Jennifer Middleton is a family physician who blogs at the Singing Pen of Doctor Jen.

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