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Clinical Leaders Discuss SOAP vs. APSO

November 18, 2015
by Rajiv Leventhal
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For years, clinician notes were written in the logical SOAP (Subjective, Objective, Assessment, Plan) format, which made sense when everything was written on paper. However, clinicians have recently argued that this format translates poorly from paper medical charts to the electronic health record (EHR). As such, a newer design, APSO (Assessment, Plan, Subjective, Objective) has been introduced and since debated in clinical circles. Proponents of APSO say that since the assessment and plan are at the top of the note, and are readily located when the EHR note is opened, it makes for a smoother format. 
For the November/December issue of Healthcare Informatics, Senior Editor Rajiv Leventhal’s feature on clinical documentation revealed that documentation still remains a huge burden for practicing physicians, years after the vast majority of them signed onto and into electronic health records. In some ways, the technology has hindered, rather than helped, documentation practices, clinicians said. More specifically, Leventhal asked clinical leaders their thoughts on the two formats, SOAP and APSO, and which was used and preferred in their respective organizations. Below are excerpts of those responses. 
Thomas Payne, M.D., medical director of IT services at University of Washington Medicine: The APSO approach puts the thinking of providers’ and the recommendations up front. This is a very reasonable approach that some like and others don’t. I see a role for it personally, since it helps you get the information you want more rapidly. Another way to reach the same objective would be for notes to be more succinct. If the reporting information you see—the subjective and objective— are to the point and succinct, that makes it easier to read through them and then see the plan and assessment that follow. But really, it’s up to the provider. 
There is a lot of tradition and expectation here. For a referring physician’s note, I usually send them with an understanding of the subjective and objective, and what I am after is their assessments and recommendations. It makes sense that the assessment and plan would be up front. I know other providers feel differently, so it’s not something I feel we necessarily have to mandate. It’s open to discussion, and for sites to experiment and find out what works best for them. 
Jonathan Teich, M.D., CMIO, Elsevier, and ER doctor at Brigham and Women’s Hospital: I don’t particularly favor a switch to APSO. Understanding the patient context as expressed in the present and recent history and exam is very important to me as an emergency doc; it helps me create a mental image of the patient, so I can better absorb and critically review the assessment and plan when they come up next.
Trenor Williams, M.D., managing partner, Clinovations, The Advisory Board Company: It was interesting when we started talking about this five or six years ago—APSO was a reactive response to note bloat and having six-page long notes. The idea is that you ideally want the assessment as the most important thing to see. What do I think is going on with the patient and what’s my plan? 
Putting that assessment in facilitates effective transitions. I’m a fan of APSO, as it makes sense from a clinical standpoint, but I still want to make sure that organizations are thinking about how they continue to optimize how they document what’s going on with that patient. Most organizations that we work with still are using SOAP more often than APSO, but I see a more continuous lean towards APSO.
Vivek Reddy, M.D., CMIO of University of Pittsburgh Medical Center’s (UPMC) Health Services Division: At UPMC, we were legitimately split on this and couldn’t come to a decision, so we brought it to our executive steering group. SOAP has since remained our standard. Our notes have become so much shorter by not auto piloting large amounts of content that’s already available in the EHR. We don’t default every radiology lab in the note automatically, for example. So by notes becoming shooter, people can get to the assessment and plan without scrolling or hunting for it. We found in our pilot work that the notes were so much shorter, and the added benefit of throwing the [assessment] at the top of note wasn’t a huge win compared to where we were prior. So we ended up sticking with SOAP, but we can always revisit it.