Thursday, January 11, 2018

In defense of SOAP notes

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. Of course, Instant Medical History would be even better, but I've yet to convince any of my employers to adopt that technology.


  1. Jen, our residency programs EHR (eClinicalWorks) template begins notes with A&P, too, and it bugs me just as much.

  2. This is a critical battle to win. The surgeons and the other proceduralists will, II suspect, favor the new mode. The patient story is not all that big a deal for them. They want to get to the quick and document so they can bill. I think this is a battle worth fighting. If primary care is to have an influence in patient outcomes this is important.

  3. I have practiced for 25 years. There is a place for SOAP and a different place for APSO. I have found APSO most useful on the inpatient service, where a patient may be present for weeks and the cross coverage services need a quick update for what has happened since the original SOAP. So for a two week admission, the first note is in SOAP, builds the story and then creates an extensive AP section. However, as the patient remains in the hospital day after day (I take care of high risk pregnancies), The APSO format becomes better for the consultants, the overnight coverage, and eventually the delivery team. However, in my clinic, the SOAP note for a visit every 2 or 4 or more weeks is the way I want to see and review my notes in prep for the day's visit. So I use both SOAP and APSO. Don't give up on one or the other, but use them where they make the most sense.