APSO Notes: what Machiavelli taught me

What does a book from the 15th century, my own pediatric record, and APSO notes have to do with modern informatics?

from wikipedia

It is the year 2009. We are 8 years into our EHR journey (Allscripts Touchworks, at that time). Physicians are dutifully recording progress notes by dictation, by typing, some using templates, to record their observations and thinking about patients in the longitudinal record. We scribble in paper charts (not every clinic is electronic yet: we have a 10 year plan to convert all the clinics).

The complaint: EVERYONE KNOWS that when the EHR team comes to town, we will put our notes into the (#$^@ computer and no one will be able to read them any more.

Exchanging illegibility for unreadability

SOAP format implies: Subjective, Objective, Assessment and Plan, and has been this way since Larry Weed proposed his organized way of tracking patient data. With brief notes, and prior to all the federal regulations on what NEEDS TO BE in the note (if you didn’t write it down, it didn’t happen), SOAP notes were terrific. Even today, surgeon notes, on a global surgical fee (eg surgeon’s can’t bill on length or complexity of notes in the perioperative period), SOAP notes can be pretty darn brief:

S: Postop day 2. No complaints. Pain improving. Not passing gas yet.
O: Vitals stable. Wound looks good
A/P: Healing well. Teaching dressing change. Anticipate DC in AM if eating.

Here’s an example of MY pediatrician’s medical record on me. 16 years of my life on one piece of paper. OK, maybe just a bit TOO succinct.

In contrast, our electronic progress notes at the time were reaching 5, 7, even 15 pages long, full of regulatory language and audit trail signatures and time stamps.

A terrible example of Emergency Department note, circa 2010. Notice the red circles around the crucial elements in this 15 page note. And that the last page is all signatures and time stamps

What is worse, these long notes are particularly hard to read on a screen. In an EHR, that means: Find Chart Review – the listing of all notes, find the note you want to read. Click to open the document, then scroll 12 pages down to find the A/P. It’s not on the Last page, because that is full of signatures and time stamps. It is about page 10 out of 12. Then, Click – scroll, scroll, scroll for the A/P of the second note.

After about 3-4 of these, you get tired and STOP LOOKING for more thinking from other doctors. IT IS TOO HARD.

What a sad state of affairs. What to do?

My solution: APSO notes!

Yes, that note is 12 pages long, yes, we need to work on shortening it. In the meantime, how hard would it be to teach docs to put their ACTUAL THINKING at the top of the note? Assessment and Plan AT THE TOP.

This way, you could write your note in the same sequence: Subjective, history, past history, etc, then Objective, exam findings, lab results, and then MOVE BACK TO THE TOP and complete your Assessment (I think this is what is going on with the patient) and Plan (This is what we’re going to do about it).

By doing so, as the patient’s history and number of visits with various specialists gets longer, it continues to be EASY to click – (no scrolling) read the A/P, Click – (no scrolling) read the next A/P. Many times easier to browse the chart and get a concentrated dose of physician/APP thinking.

In my mind, I’m a genius.

How hard could it be to change doctor behavior?

You know what is coming. I did not.

I built a new note template: APSO format, to sit alongside SOAP format. I user-tested it in 1:1 meetings with about 80 colleagues, who all agreed “This seems better, easier.”

I launched the note template, held my breath …

I got to a 70% adoption rate. Woo-woo.

Many folks (EVEN AMONG MY SELF-PROCLAIMED FRIENDS) did not change behavior. “Oh, I forgot.” “Oh, I am planning on trying that sometime.” “Oh, I was very busy and running behind. Not today.”


Another failure for the Failure Resume.

About this time, I was reading Kotter’s Leading Change and also Machiavelli’s the Prince. Between the 2 texts, I had some insights.

1. The Burning Platform (Leading Change)

I knew we were headed to adopting a new EHR platform in 2011, which was sure to cause significant disruption in many ways. Never waste a good crisis. Use the Burning Platform: when everyone jumps, give them a good place to land.

If you’re going to mandate APSO notes in the EHR, why not do it from the ground-zero of installing a new EHR? This is what I set out to do. The ground-work: the standard template for all progress notes would be APSO format: Assessment/Plan/Subjective/Objective.

I told the white lie: “Sorry, our new EHR only comes with APSO notes.”

I got the leadership to back me up (see below): APSO notes are much more readable than standard scrolling SOAP. This is the right moment to make this major change in policy. Don’t let individual complainants revert back without a thorough review with all leaders.

2. How to build meeting consensus  (Machiavelli)

Having re-read my Machiavelli text, I set up my next plan. I needed medical leadership consensus on making such a broad-ranging change.

By the way, for those of you who equate Machiavelli with self-serving, power-hungry, win-at-all-costs reprobates, well sure. HOWEVER, his text is ALSO full of practical advice for leaders.

He states: if you go into a meeting and you do not already know how everyone will vote, you have not done your job.

There are 40 members of the multi-disciplinary Ambulatory Medical Directors group; they are a rowdy, tough-to-wrangle group with strong egos, lots of opinions, and rare consensus across primary care, medical specialty and surgical specialties. If you have worked any amount of time in healthcare, perhaps this is familiar to you.

I determined to meet 1:1 with the majority of the group, including of the most influential members.

My tactic:

CT: “Don’t you hate it when it is hard to read the notes of [other specialty here]?”
CT’s targeted medical director: “Yes! Their notes are TERRIBLE. Ours are fine, by the way.”
CT: “Right! Well, I’m planning on enforcing APSO format for their notes so it is easier for us to read them.”
Target MD: “That sounds great. It is SO NEEDED.”
CT: “However, in order for me to get them to change to APSO, I need YOUR specialty to change to APSO. We need to be unified and apply pressure to THEM to change.”
Target MD: “But, our notes are fine. We don’t need to change.”
CT: “I can’t do this without you. The actual change for you is minimal. Just start part way down the note at Subjective (that is F2 key pressed 2 times), your patient visits and documentation sequence doesn’t change, just the final display of the note is different. For a minimal investment on YOUR part, we ALL benefit from THEIR NOTES being more readable. How about it?”
Target MD: “Hmm. I suppose it is worth it. You can get THEM to change though?”
CT: “Yup, you give me your approval for your specialty, and I will get THEM to change.”
Target MD: “Deal. Makes sense. Minimal change for us, big improvement on their part.”

CT repeats this conversation WITH EVERY OTHER MEDICAL DIRECTOR. Each of whom have the same thing to say about every other specialty. “We’re great, but those guys are terrible.”

As a result, the following Committee discussion was a non-discussion: “CT is proposing standard APSO format for all notes written in Epic. Any discussion?” “Nope. Makes sense to me.” “Sounds ok.” And then discussing some minor concerns, we were done.


Perhaps 20 hours of planning and 1:1 meetings for a 5 minute agenda item.

What’s that? This is unworkable for the majority of decisions? You are absolutely right. We pull out all these techniques ONLY for the BIG decisions. But it can and does work. To this day, Primary care notes (we write about 1 million a year), are 100% APSO format, and specialties are about 88% APSO.

CMIO’s take?

Years later, I gave this talk at Epic UGM and it has become an Epic Classic (link requires userweb login). In subsequent years, readability and note format continue to be debated, and at one point I was referred to in a UGM session as “unlike those Radical Extremists at UCHealth who standardized on APSO, we can’t get our people to adopt it like that.”

Thanks for the … compliment?

And now you know how this particular sausage was made. Thanks to Machiavelli and Kotter, and all the smart people before us.

Author: CT Lin

CMIO, UCHealth (Colorado); Professor, University of Colorado School of Medicine

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