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

Background: The follow-up note is the most with this minimum work requirement in mind, was common chart entry. Its form has evolved over the received favorably by practicing internists. twentieth century but no absolute requirement is mandated. For all but the most trivial of problems, follow up visits are required for both diagnosis and Objectives: 1) determine usage of two common management. In the modem era of medicine, progress note formats amongst practicing internists at documentation of these visits have varied from a community-based teaching hospital. 2) determine cryptic "one-liners" on index cards to detailed whether there is a minimum work requirement for the written or dictated notes kept in manila folders. The follow-up encounter. 3) design an electronic medical conventional manila file records were largely sourcerecord achieving this minimum work requirement. oriented and time-oriented. That is, the record was subdivided in sections such as patient notes, lab, xDesign: Self-administered, anonymous survey. ray, insurance forms, etc. in chronological order. The patient's problems were woven together in the Participants: Forty-one Internists at a teachinfg progress note according to the style of the individual hospital. practitioner. This led to difficulties in following problems over time, especially in shared records with Measurements: Self-administered, anonymous varying data collection styles. In 1968, Weed questionnaire on usage of Subjective-Objective proposed a Problem Oriented Medical Record Assessment Plan (SOAP) and Interim History(POMR) which has been largely accepted as the Exam-Assessment-Plan (HEAP) note taking formats. proper way to organize the record. This provided a In addition, physicians were asked if they agreed that focus for subsequent progress notes that clearly the minimum work of the follow-up visit was to: 1) delineated the major issues facing that patient. The Review the last Assessment and Plan, 2) Review the template for the follow up visit that Weed created returned plan results, and 3) Discuss the current was the Subjective, Objective, Assessment and Plan, status ofthe Problem. or SOAP note. This model for the medical follow-up note is the standard taught in medical schools today. Results: The use of HEAP and SOAP was In spite of this, however; it is widely perceived that approximately equal. 8 physicians exclusively used the SOAP note has not become the dominant form of SOAP and 9 exclusively used HEAP. The majority of record keeping in the office practice of medicine. In physicians used both formats interchangeably, with addition, the POMR and SOAP notes were supposed no clear dominant format. 37 of 41 physicians agreed to lead to the rapid computerization of the medical to the minimum work of the follow-up visit. Using record. Many vendors based their computerized this information, a next generation computerized medical records (CMR) on this format. medical record was developed and presented to Unfortunately, the success of CMR's has been physicians for evaluation. minimal with actual use levels ranging between 14%. This study examines the use of the SOAP note in Conclusions: Neither SOAP nor HEAP note format clinical practice as well as a minimum requirement of would be a viable standard for a Computerized the follow-up note. The latter, which may be Medical Record (CMR). The minimum work of the considered the "minimum work of the follow-up follow-up visit suggests a more universal standard to visit", was then used to develop the next generation build the CMR upon. One example CMR, developed CMR. 1067-5027/00/$5.00 @ 2000 AMIA, Inc. 1088