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The Skeptical Convert 1/25/13

January 25, 2013 Robert D. Lafsky, MD 4 Comments

APSO Fact and Fiction

I sit on an Epic implementation advisory committee for my hospital’s multi-hospital organization. From time to time, we are asked to make policy recommendations. One issue brought to our attention concerned the formatting of medical assessment notes, especially the part where the practitioner actually gets around to stating his or her actual opinion about what’s going on and what to do next. 

The issue had to do with whether that information would be placed at its usual seat of honor at the end of the report, or whether it should be placed up at the top. The shorthand for the formatting issue would be “SOAP vs. APSO”, where the four letters stand for “subjective, objective, assessment, plan.”  

In medical school, we are taught the traditional “history and physical” reporting format when evaluating a new patient or problem. The patient’s own story comes first– information considered “subjective” (yes, you can argue that the subjectivity is as much in the head of the practitioner as the patient, but a digression here). What followed traditionally was a detailed physical examination.  

In the mid-20th century, Lawrence Weed, MD coined the SOAP terminology, incorporating the reality that lab tests and imaging had become major factors in the medical workup. “Objective” became his bucket term for doctor- and system-generated information beyond the patient’s history.  

But whether you call the next section “impression”, “assessment” or “differential diagnosis”, the question it attempts to answer is the whole point of the exercise. What, doctor, is your opinion about what is going on here? What do you think is wrong, and if not that, what else might it be? The plan for what to do, of course, should follow logically from that.

The argument of APSO proponents is that they don’t really want to change this, but that EMR reports have become bloated by lots of templated and imported information. Someone reviewing them just wants to get to the conclusions and recommendations of the attending or consultant. So, put that at the top. Their position is that no matter how you format the information, the workflow and “thoughtflow” (a nickel to Dr. Bierstock) stay the same.

Is that true? I have trouble believing it. In fact, deep down I really dislike the APSO format, and I didn’t like it before any computerized reporting was developed. 

Many practitioners, especially medical subspecialists, dictate their consult notes that way. They’ll say they work in their heads down from the subjective / objective, but when they dictate, they do start with the conclusions. When I read down the page of an APSO consult, I often see gaps in basic structure and/or clinical information that may have been included if the author had stayed in order. From my own experience, dictating in traditional order, I do in fact sometimes revise my opinion or add additional diagnostic options by the time I get to the end.

But really, I can’t get that worked up about it (that’s why I dumped my original title:  “Let’s send APSO to Lhasa”). The reason is that APSO notes at least have some sort of thought-through assessment in them. Frankly I read a lot of notes that dutifully go through the motions of a history and physical, but then the conclusion — often compressed into some ghastly mutant section called the “Assessment/Plan” — blandly restates the available findings and problems and goes straight to the tests and consults that will be requested. If you have nothing to say, you might as well spit it out at the beginning. Saves time for me, anyway.

Will Epic straighten these problems out or exacerbate them? I’m out of space now, but Epic go-live is in two months. Stay tuned.  

Robert D. Lafsky, MD is a gastroenterologist and internist in Lansdowne, VA.

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Currently there are "4 comments" on this Article:

  1. Robert,

    This is a great post.

    I completely agree with you that Lawrence Weed’s traditional SOAP note format better supports the cognitive process physicians use to reason about a patient’s health issues.

    I also agree that the APSO format is a mere expedient because EHR notes tend to be so bloated.

    In theory, EHRs have the potential to provide different screen views of the same data for different purposes. For instance, while the billing department requires a comprehensive (bloated) view of the data, physicians need a focused (non-bloated) screen view that displays only the positive findings and pertinent negatives, with details available on demand.

    In practice, most EHRs have not developed this potential.


  2. Is there an interim solution of tagging the document with hyperlinks to the section so those needing to cut to the Assessment can do so? In theory all the NLP CLU work may start to address some of this or at least for a given specialty highlight key words like occurs with some search engines.

  3. I have been a patient of Dr. Lafsky’s for about 15 years now. He is one of the few docs that gave me paper copies of my medical records at no charge when I asked for them about 5 years ago.
    I am looking forward to my annual exam and getting my medical records electronically the next time I visit.

  4. Fans can be the worst (best) critics. Epic has a blind spot in this regard. To create displays you build “reports” made up of “print groups”. Do you think they are still an EHR? or a computer version of a paper record? Epic is an electronic artifact, but you cannot make use of hyperlinks to jump from one section to another. You cannot create the non-bloated “displays” that users have begged for over the last 8 years that I have been familiar with the vendor. Don’t get me started on the actual printed reports that we send to external users. APSO is the least of our worries in this regard. APSO was created because the Epic monolith has not been moved by the pleas of thousands of users for readable DISPLAYS and usable printed communications. Like the Samsung commercial “We gonna get that in the next version, right?”

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