The Evolution of Office Notes and the EMR: The CAPS Note

By Peter Evans, MD, PhD

Until the advent of the electronic medical record (EMR), patient charts were filled with handwritten notes documenting visits to the office and read in linear fashion, starting with the patient’s perspective of the problem, then the objective findings of the physical examination, supporting objective data, and finally, the physician’s assessment and treatment plan.

The reliable subjective, objective, assessment, plan (SOAP) approach to notes first advocated by Lawrence Weed in the 1960s did a remarkable job of conveying the physician’s thought process, supporting data, and conclusions. The notes were brief by necessity, as the physician did not want to spend time writing extraneous information.

In the age of the EMR, large quantities of data are included in the patient notes that have no connection to or do not clearly convey the physician’s thought process. In 2013, 78 percent of office-based physicians were using EMRs, an increase from 18 percent in 2001 and an adoption rate accelerated by federal government policies. But many physicians still do not feel competent reading or writing notes in an EMR and still prefer to read succinct narrative notes.

This problem is not unique to seasoned physicians. Medical students are also failing to learn how to appropriately document office visits in the EMR, as 52 percent of medical schools prohibit them from writing in patient charts.

As a result, we believed that a reassessment of Dr. Weed’s problem-oriented approach to the medical record was required to streamline the EMR and facilitate the way information is conveyed between providers of the patient’s care. Too often, large quantities of laboratory, radiographic, and pathology results are dumped into the record, burying pertinent information about the physician’s thought process, assessment, and evaluation and treatment plan and making it difficult to quickly and efficiently determine the plan.

CAPS: A modification of SOAP

We recently adopted an approach to office notes that is a modification of the SOAP note. While physicians often gather subjective, objective, and laboratory information to deductively formulate a diagnosis, it is not necessary to document it in the traditional deductive format in the EMR when the information is readily accessible in other areas of the record. Furthermore, a deductive format in the modern EMR produces excessively lengthy notes that require pages of screen scrolling to find the key elements required for effective patient care. This is time-consuming and is a daily obstruction to patient care.

The format that we have been using for almost 10 years still allows the physician to adhere to the problem-oriented medical note philosophy. We call it the CAPS note, which stands for concern, assessment, plan and supporting data. This approach allows others involved in the patient’s care to efficiently extract critical components (assessment and plan for a specifically stated problem) while still allowing the inclusion of supporting data for reference and for coding and billing.

The structure of the CAPS note is:

• Concern: The primary purpose of the patient’s visit, including the history of the present illness, as conveyed by the patient, and the current status of the concern.
• Assessment: A succinct definition of the patient’s concern along with an accompanying medical diagnosis.
• Plan: The clinician’s immediate and long-term intentions for addressing the patient’s concern or condition.
• Supporting objective and subjective information: All supporting objective data, starting with the physical examination, then the results of laboratory and radiographic tests, and any other information that contributed to the clinician’s medical reasoning. Then, subjective information is included, such as the patient’s past medical, surgical, family and social histories; current medications; allergies; and a comprehensive review of systems.

This structure keeps the most important information at the top when the encounter is opened on the computer screen and eliminates the need for unnecessary scrolling and searching, not to mention frustration and delays in patient care. Other less pertinent information appears toward the bottom of the record.

The APSO note vs. the SOAP note

Frustration over the difficulty of finding the most pertinent information in the EMR—the assessment and the plan—has led others to propose a rearrangement of the traditional SOAP note. The APSO (assessment, plan, subjective, objective) note was created for inpatient daily progress notes, a situation in which the patient’s concern is unlikely to change dramatically on a daily basis and was not intended for use in outpatient clinics. While the APSO format does allow colleagues rapid access to the physician’s assessment and plan, it abandons the patient-centered approach of Dr. Weed’s problem-oriented medical record in that it makes it more difficult to find why the patient initially sought care, how long the patient has had the problem, or if there were prior attempts to treat it. These critical details are buried in the bowels of the note.

The advantage of the CAPS note is that it retains the patient-centered, problem-oriented spirit of the SOAP format, while moving potentially supportive yet distracting data fields to later in the note. Thus it is applicable to inpatient and outpatient settings.

In the inpatient setting, the fields remain in the same order, but the chief complaint is often the admitting diagnosis or surgical procedure, followed by a quick line on the interval history. The assessment and plan can then follow in much the same way as it would in the outpatient setting, and below that are the patient’s daily laboratory results, radiographic studies, physical examination findings and any other relevant supporting data. This format allows rapid access to critical information needed by either consultants or cross-covering practitioners who primarily want to know why the patient was admitted, the status and the primary team’s plan.

Any template has limitations

Any standardized template for progress notes in the EMR has limitations. The CAPS format would be easier for a hospital-based physician, who typically addresses one or a small number of concerns, than for an office-based general practitioner who may have to address a multitude of comorbidities in a single visit.

Also, different physicians use the EMR differently. For example, a survey of 1,088 physicians found that 60 percent of primary care physicians used templates vs. only 34 percent of specialists, and that 38 percent of specialists relied mainly on dictation.

The CAPS approach to the office visit note offers a blend of a template and free text, either typed or dictated, while keeping a structured format that permits others participating in the patient’s care to easily extract desired information. The template can easily be brought up in the patient’s chart, then by either typing or using voice-recognition software, the patient’s chief complaint, history of the present illness, assessment and plan can be easily completed.

The CAPS format should continue to allow notes to fulfill medicolegal and billing obligations, but without cluttering true clinical reasoning. As more institutions adopt an open-notes policy, permitting patients to freely browse their own medical records, patients will benefit from a clearly structured clinical note that focuses on their problem and the practitioner’s solution. This provides patients a sense of validation and reassurance that the note starts with their concern and history, followed by the practitioner’s assessment and plan, so they can easily affirm that they were accurately heard and can identify the diagnosis given to them by the medical practitioner and the plan moving forward.

Since a return to succinct, albeit often illegible, handwritten clinic notes is impossible, our proposed method of documenting a clinic visit embraces the EMR with a concise yet comprehensive clinic note.

This article originally appeared in Cleveland Clinic Journal of Medicine.