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

Transcription

1 The Follow up note: Format and Requirements, Specifications for the Computerized Medical Record Kim Charles Meyers, MD 1, Andrew S. Kanter, MD, MPH 2, Regis Charlot, MS 2, Frank Naeymi-Rad, PhD 2 1 Evanston Northwestern Hospital, Evanston, IL Intelligent Medical Objects, Inc., Northbrook, IL 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 folders 1,2. The conventional manila file records were largely sourceoriented 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, Weed 3 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 4, 5. record keeping in the office practice of medicine 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. 1

2 METHODS This study involved a survey placed in the mailboxes of all 172 Internists in the department of medicine at Evanston Northwestern Hospital. This facility is a community-based teaching hospital with both residents and medical students. The recipients were asked to respond anonymously to the survey and return it to the author. The number of respondents was 41, a 24% response rate. The survey was as follows: I would like your help by answering this brief questionnaire. This involves your thoughts and behaviors regarding certain aspects of the medical record as you currently keep them. For purposes of discussion I would like to be very clear on the definition of the SOAP note, which was defined by Weed in Subjective = How the patient has been feeling or what they have been thinking since the last visit. Objective = Results of tests, consultations and physical exam findings Assessment = progress the patient has made, differential diagnosis Plan = includes a primary goal as an agenda for providing more information, treatment, or education An alternative form for the follow up visit has been referred to as the Interim History, Exam, Assessment and Plan (HEAP note). In that scheme the follow up flows as follows: History = any returned test or consultation will likely be commented upon along with patient commentary and responses to MD s questions. Exam = Physical Exam findings only Assessment = progress the patient has made, differential diagnosis Plan = includes a primary goal as an agenda for providing more information, treatment, or education The difference in the formats resides in the content of the S & O vs. the H & E. For example, consider a follow up visit in a patient with headaches that you thought was migraine. The plan was to get an MRI, Sed Rate and seek consultation with a neurologist named Dr. Hammerton. In the SOAP format, the note you would write would be as follows: O: MRI negative, Sed Rate 10, Dr. Hammerton feels headaches are migraine and suggests Beta Blockers. NAD, fundi normal, reflexes 2 plus patellar and biceps A: Negative workup and good response suggests Migraines P: CPM using imitrex as needed In the HEAP format the note is: H: MRI negative, Sed Rate 10, Dr. Hammerton feels headaches are migraine and suggests Beta Blockers. Since last visit the patient feels the Imitrex was helping. She does not want Beta Blockers E: NAD, fundi normal, reflexes 2 plus patellar and biceps A: Negative workup and good response suggests Migraines P: CPM using imitrex as needed Considering this, how often do you use the SOAP format in your follow up encounters: Per Cent : Other Percentage: Interim History, Exam, Assessment and Plan Per Cent: Other Percentage: Regarding the follow up note for individual problems, do you agree that the minimum work of the follow up visit is to: 1) review the last Assessment and Plan 2) review the returned plan results 3) discuss the current status of the problem Y N feel free to comment on back of sheet regarding any alternative definition you may have for this or the follow up note. RESULTS The physicians could choose a percentage of SOAP and/or HEAP in their response so they did not have to exclusively use one form or the other. The results are shown in Table 1. S: Since last visit the patient feels the Imitrex was helping. She does not want Beta Blockers 2

3 SOAP Percentage Used No. of Physicians 100% 8 95% 1 90% 3 75% 8 50% 4 25% 5 5% 1 0% 12 HEAP Percentage Used No. of Physicians 100% 9 95% 1 90% 1 75% 5 50% 4 25% 8 10% 3 5% 1 0% 9 Table 1. Percent usage of SOAP and HEAP Physicians answers generally added up to 100 percent, however 7 physicians used another format for at least some percentage The agreement regarding the minimum work of the follow up visit was 39 Yes and 4 No as shown in Figure 1. Note: 3 of the 4 No s had additional comments as follows. One respondent I do not understand the question. One respondent agreed with reviewing the last assessment. The final no responder did not want the monitoring police holding me to be this explicit with every progress note, assessment and plan good enough. Using this information, and working with a medical software company, Intelligent Medical Objects, Inc. (IMO), the authors designed a next generation computerized medical record system. Built upon a sophistical database system, flexible user interface, and a rules engine, this CMR called O-HEAP (for Orientation-History, Exam, Assessment and Plan) provided an automated process for capturing the minimum work of the follow-up visit. For example, assume that one saw a patient with headaches as described in the example provided above. The first visit would capture the initial information, make the assessment of headaches and then order the three plans: MRI, Sed. Rate, and Consult. The next time the patient was seen, O- HEAP prompted for the status of the problem and each prior plan (see Figure 2), adjudicated the results of the prior plans (see Figure 3), and once the new assessment and plan were entered, generated the following report: The patient is a 20 year old female Problem MIGRAINE: Added on 03/01/2000 Last visit on 03/01/2000 Assessment: HEADACHE (Working Diagnosis). Possible: MIGRAINE, CLUSTER HEADACHE. Plans: MRI, BRAIN; SEDIMENTATION RATE, ERYTHROCYTE; Consult with Dr. Hammerton Yes NumberResponses No MRI- Compliant. Ordered: 3/1/2000. Completed: 3/1/200. Result: Normal. Results told to patient. Added to Test History. SEDIMENTATION RATE - Compliant. Ordered: 3/1/2000. Completed: 3/1/200. Result: Normal (10 mm/hr). Results told to patient. Consult with Dr. Hammerton- Compliant. Ordered 3/1/2000. Completed: 3/5/2000. Comment: Dr. Hammerton feels headaches are migraines and suggests beta blockers. Figure 1. Response to Regarding the follow-up note for individual problems, do you agree that the minimum work of the follow up visit is to: 1) Review the last Assessment and Plan, 2) Review the returned Plan Results and 3) Discuss the current status of the Problem. Patient reports that the Headache is improved. Note: Does not want to take beta blockers. Exam: General: NAD HEENT: Fundi Normal Neuro: Reflexes 2+ biceps and patellar bilaterally 3

4 Assessment & Plan: HEADACHE (Superceded Diagnosis). Replaced by MIGRAINE (Working Diagnosis). MIGRAINE (Working Diagnosis), improved. Negative workup and good response suggests migraines. Will treat as such. Imitrex 25 mg 1-2 Tab PO PRN headache When this CMR was presented to practicing internists in focus groups, the response was extremely positive. A controlled-study of the O- HEAP CMR is currently being designed. Figure 3. Example of prior test adjudication screen. Clicking on plan name in organizational window above, prompts with the following screen (filled out for this example). DISCUSSION Figure 2. O-HEAP organizational window showing how patient with Migraine who had prior plans automatically prompts to record information and generate Orientation paragraph. The responses to the survey regarding the HEAP vs. SOAP progress note format indicate that there is no strong predilection for either format by many physicians. It is also of interest that many physicians feel they use both formats in varying percentages. This indicates that physicians feel comfortable mixing the form of their follow up notes as they feel the need. Overall it would appear that both the HEAP and SOAP note formats are widely used among these physicians, but neither could claim to be the standard when it comes to follow-up notes. The data on the minimum work of the follow up visit is striking and independent of which format physicians used for progress notes. A remarkable 37 out of 41 respondents agreed that 1) reviewing the last Assessment and Plan, 2) reviewing the returned plan results, and 3) discussing the current status of the Problem was the minimum work of the follow-up visit. This implies that the idea of a minimum required work rule is more fundamental to the follow-up encounter than the particular format of the note. 4

5 An important implication of this finding is how it could effect the design of CMR s. The importance of follow-up visits to the design of the CMR is obvious as a patient s problem has only one initial visit; from then on, all notations about it will be in follow-up visits. Therefore, the progress note in the CMR is the most common interaction the physician needs to document on the computer. Dr. Lawrence Weed makes the point quite emphatically, Progress notes are the most critical part of the medical record 6. This underscores the importance placed in the diagnosis and management of problems over time. The logical extension of this statement is that if the progress note isn t handled well in the CMR, the CMR will not be adopted. CMR s have had less than 4% 7 adoption by medical practitioners for years with little sign of change on the horizon. The vast majority of CMR s have adopted SOAP or free text typing/dictation as the standard for the follow-up note 8, 9. That approach, in these authors opinion, has been a major cause of the current failure to adopt the computerized medical record. A record based on orientation around the problem via the last assessment and plan, plan results and current status of the problem, i.e. the minimum work of the follow-up visit, would appear to be a superior standard. The Orientation History, Exam, Assessment and Plan (O-HEAP) format 10 incorporates this structure and has now been developed into the next generation CMR. In conclusion, this survey suggests that there is a minimum work requirement of the follow-up visit. There was far more agreement on this than on individual physician s usage of the SOAP or HEAP format for their notes. The implication for the development of the CMR is fundamental. The follow-up note, which is the most common encounter in medicine, should spring from the minimum work of the follow-up visit, not the SOAP or HEAP note format. At least one CMR designed upon this principle has received initial positive response from practicing internists. ACKNOWLEDGEMENTS There was no financial support for this study. Development of the O-HEAP CMR was supported by the Evanston Northwestern Hospital Soreng, Solis, Cobb Chair of Medical Informatics and Intelligent Medical Objects, Inc. REFERENCES 1. Collen MF. Medical Informatics in the United States ( ). American Medical Informatics Association. 1995: Stoeckle JD, Billings JA. A History of Historytaking: The Medical Interview. Journal of Internal Medicine. 1987; 2: Weed LL. Medical Records that guide and teach. NEJM. 1968; 278: Meyers KC, Miller HJ. The Importance of Cleaning Up SOAP. [Letter] Acad. Med. 1997;72: Rubin AS. Another Way to Enhance SOAP s Usefulness. [Letter] Acad. Med. 1998; 73: Weed LL. Medical Records Medical Education and Patient Care. Chicago: Year Book Medical Publishers; 1969: Frieden J. Real World Benefits to Online Records. Internal Medicine News.1998; Vol. 31, No. 18: Aghili H, Mushlin R, Williams R, et. al. Progress Notes Model. Proceedings AMIA Symp.1997: Tange H, Hasman A, de Vries Robbe P, et. al. Medical Narratives in Electronic Medical Records. International Journal of Medical Informatics. 1997; 46: Meyers KC, Miller HJ, Naeymi-Rad F. The Problem Focused Knowledge Navigation: implementing the problem focused medical record and OHEAP Note. Proceedings AMIA Symp.1998: