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The Skeptical Convert 1/25/13

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.