HomeLast Word → Whom Does the EMR Serve? Who Owns and Who Needs THE STORY?

Whom Does the EMR Serve? Who Owns and Who Needs THE STORY? Print E-mail
Written by A Country Doctor Writes   
Saturday, 17 August 2019 12:22

I have advocated before for putting a visit synopsis at the beginning of each visit note. I have called that the aSOAP note. I think that works immensely better than APSO notes that only rearrange the order of the elements. The reason I say that is that in today's EMR notes, it's too darn hard to find THE STORY. If a note is half a dozen pages or scrolls long, why would I want the medication changes and the reason why they were made at opposite ends of the note? The order means less than the distance between them in my opinion. The way I approach reading a note is with the two questions "What happened in the last visit?" and "Why was that the clinical decision?" In more and more of my office notes I answer these two questions for future readers, which would include me, in temporal, typographical and spatial connection with each other, right on top.

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