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. Don’t 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 health care 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.
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