Publications

The Follow-up note: Format and Requirements, Specifications for the Computerized Medical Record

05/19/2000

Kim Charles Meyers, MD¹, Andrew S. Kanter, MD, MPH², Regis Charlot, MS², Frank Naeymi-Rad, PhD²

¹Evanston Northwestern Hospital, Evanston, IL 60201
²Intelligent Medical Objects, Inc., Northbrook, IL 60062

Abstract
Background: The follow-up note is the most common chart entry. Its form has evolved over the twentieth century but no absolute requirement is mandated.

Objectives: 1) determine usage of two common progress note formats amongst practicing internists at a community-based teaching hospital. 2) determine whether there is a minimum work requirement for the follow-up encounter. 3) design an electronic medical record achieving this minimum work requirement.

Design: Self-administered, anonymous survey.

Participants: Forty-one Internists at a teaching hospital.

Measurements: Self-administered, anonymous questionnaire on usage of Subjective-Objective - Assessment - Plan (SOAP) and Interim History-Exam-Assessment-Plan (HEAP) note taking formats. In addition, physicians were asked if they agreed that the minimum work of the follow-up visit was to: 1) Review the last Assessment and Plan, 2) Review the returned plan results, and 3) Discuss the current status of the Problem.

Results: The use of HEAP and SOAP was approximately equal. 8 physicians exclusively used SOAP and 9 exclusively used HEAP. The majority of physicians used both formats interchangeably, with no clear dominant format. 37 of 41 physicians agreed to the minimum work of the follow-up visit. Using this information, a next generation computerized medical record was developed and presented to physicians for evaluation.

Conclusions: Neither SOAP nor HEAP note format would be a viable standard for a Computerized Medical Record (CMR). The minimum work of the follow-up visit suggests a more universal standard to build the CMR upon. One example CMR, developed with this minimum work requirement in mind, was received favorably by practicing internists.

For all but the most trivial of problems, follow up visits are required for both diagnosis and management. In the modern era of medicine, documentation of these visits have varied from cryptic "one-liners" on index cards to detailed written or dictated notes kept in manila folders1,2. The conventional manila file records were largely source-oriented and time-oriented. That is, the record was subdivided in sections such as patient notes, lab, x-ray, insurance forms, etc. in chronological order. The patient's problems were woven together in the progress note according to the style of the individual practitioner. This led to difficulties in following problems over time, especially in shared records with varying data collection styles. In 1968, Weed3 proposed a Problem Oriented Medical Record (POMR) which has been largely accepted as the proper way to organize the record. This provided a focus for subsequent progress notes that clearly delineated the major issues facing that patient. The template for the follow up visit that Weed created was the Subjective, Objective, Assessment and Plan, or SOAP note. This model for the medical follow-up note is the standard taught in medical schools today. In spite of this, however; it is widely perceived that the SOAP note has not become the dominant form of record keeping in the office practice of medicine4, 5. In addition, the POMR and SOAP notes were supposed to lead to the rapid computerization of the medical record. Many vendors based their computerized medical records (CMR) on this format. Unfortunately, the success of CMR's has been minimal with actual use levels ranging between 1-4%7. This study examines the use of the SOAP note in clinical practice as well as a minimum requirement of the follow-up note. The latter, which may be considered the "minimum work of the follow-up visit", was then used to develop the next generation CMR.

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