Better documentation in the inpatient medical record

An expert group recently issued recommendations on documentation in the inpatient electronic health record. They acknowledge common problems with the note such as ‘note-bloat’ (increased length and complexity of a note with a decrease in the meaningful content and decrease in readability), errors due to the ‘copy and paste’ phenomenon, plagiarism, and ‘boilerplate’. Among the changes proposed by this group is a change in the structure of the progress note from ‘SOAP’ to ‘APSO’, where the meaningful clinical content is placed at the beginning of the note and the material that is imported from other parts of the record or copied and pasted is in the latter part of the note.

Association of medical directors of information systems consensus on inpatient electronic health record documentation, 2013