by J. Paul Spencer, CPC, COC
November 4th, 2016
Thirty years before the first set of evaluation and management , or E&M guidelines was released, Dr. Lawrence Weed developed a format for the improvement of what was then a segmented medical record into a problem-oriented medical record for patients. This format evolved into the "SOAP" note, representing an acronym for Subjective (history), Objective (physical examination), Assessment and Plan. Since introducing this format to a wider audience in 1968, the SOAP note has become the standard for the documentation of physician encounters.
The advent of Electronic Medical Records, coupled with a new generation of tech-savvy physicians, has brought changes to Dr. Weed's original format. The latest modification is the "APSO" Note, in which the Assessment and Plan is placed at the beginning of E&M encounter documentation. Younger physicians, particularly in the hospital environment, have embraced this method as a way for subsequent providers on a case to avoid reviewing clinical information collected by previous providers in order to diagnose the patient.
When asked about this development, Dr. Weed, now in his 90s, stated that the "APSO" note format transforms the documentation to "provider-centered rather than patient-centered" and places "opinion before the facts". Despite his objections, larger EMR vendors are now
designing templates that put a premium on quick access to the assessment and plan.
From an auditing perspective, a design that simplifies the physician's process modifies the tasks of the auditor. As auditors, we have been conditioned to perform audits of documentation in its traditional order of history, examination and medical decision making / assessment and plan. Yet despite a variation in recognized order of documentation elements, the auditor's task remains the same.
In the format of the provider's choosing, the documentation of any E/M service must have clear documentation of a chief complaint, history, examination, and clear documentation of a physician thought process that focuses on the conditions assessed during the visit.
In one way, the APSO note makes the job of the auditor easier. When documentation begins with the plan of care for conditions assessed during the visit, auditing becomes less about discovery of facts from a clean slate, and more of a forensic investigation to find if the remainder of the documentation fits the conclusions reached by the physician.
In most APSO notes, the history of present illness (or H.P.I) is shown either just below or intermingled with the assessment and plan. From an auditing perspective, this placement offers advantages beyond the simple counting of bullet points. In this format, connections can be more easily made between the narratives of the patient and the provider. Conditions assessed should readily appear as part of the HPI. If it is not, the review of systems and examination of the patient should make it apparent that the problem was first brought forward and assessed during that visit.
The above is also true when determining ICD-10 diagnoses to be included on a claim submission. If a condition was not meaningfully assessed from patient interaction during the visit audited, and the assessment and plan of care only references the condition in passing, with no changes to the treatment regimen, it would stand to reason that this condition was not the primary focus of the visit. The decision whether or not to include the diagnosis on a claim then becomes an easy one.
As with any other audited chart from an electronic medical record, the value of the content of the documentation will be directly proportional to the comfort level of the provider entering the information. Whether it is a "SOAP" note or an "APSO" note, hovering over both are the E/M Guidelines, which show no signs of changing after twenty years of existence. While physicians can be educated on deficiencies with regard to documentation and (possibly) coding, the format of the note should be left up to the physician. In the end, the documentation must serve the continuing medical needs of the patient, and reflect the thought process of the physician providing care.