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The American Journal of Accountable Care March 2017
Use of Postacute Care After Discharge in Urban and Rural Hospitals
Robert E. Burke, MD, MS; Christine D. Jones, MD, MS; Eric A. Coleman, MD, MPH; Jason R. Falvey, DPT; Jennifer E. Stevens-Lapsley, PT, PhD; and Adit A. Ginde, MD, MPH
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Steven D. Pizer, PhD; Michael L. Davies, MD; and Julia C. Prentice, PhD
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Successful Implementation of APSO Notes Across a Major Health System
Amber Sieja, MD; Jonathan Pell, MD; Katie Markley, MD; Christine Johnston, MD; Robert Peskind, MD; and Chen-Tan Lin, MD
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Heidi Schwarzwald, MD, MPH; Agnes Hernandez-Grande, MD; Stephanie Chapman, PhD; and Stephanie Marton, MD, MPH
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Jennifer L. Wiler, MD, MBA; Harold D. Miller; and Nir Harish, MD, MBA
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Maryam Alvandi, DHS, MHS

Successful Implementation of APSO Notes Across a Major Health System

Amber Sieja, MD; Jonathan Pell, MD; Katie Markley, MD; Christine Johnston, MD; Robert Peskind, MD; and Chen-Tan Lin, MD
In this study, the authors demonstrate widespread adoption and satisfaction with the novel APSO (Assessment, Plan, Subjective, Objective) format for progress notes at a large, integrated health delivery network.

Objectives: To determine whether inpatient and outpatient clinicians prefer and/or adopt the APSO (Assessment, Plan, Subjective, Objective) notes versus the SOAP (Subjective, Objective, Assessment, Plan) format of notes for their clinical documentation.

Study Design: This is a retrospective chart review of inpatient and outpatient clinician notes performed in early 2014. A clinician satisfaction survey was performed to measure satisfaction with APSO format notes.

Methods: We documented the note format, SOAP versus APSO, of almost 2000 progress notes from a large, integrated health delivery network comprising 1 academic and 4 community hospitals and more than 100 outpatient clinics. We surveyed clinician authors who were attending academic and community physicians, medical residents, and advanced practice providers to determine their satisfaction with APSO format notes.

Results: Of 894 outpatient notes reviewed, 94% were APSO format. Of 1057 inpatient notes reviewed, 79% were APSO format. At the academic hospital, 94% of inpatient notes were APSO, and there were no dictated inpatient notes. Our clinician satisfaction survey response rate was 18% (564 of 3170). Eighty-percent of respondents were “satisfied” or “very satisfied” with APSO notes as both authors and readers.

Conclusions: We were able to demonstrate widespread adoption of APSO notes in the inpatient and outpatient academic and community settings. A large number of clinicians demonstrated willingness to use new tools to improve note efficiency and communication among care teams. This study evaluates APSO as a novel note type that could decrease the time clinicians spend in chart review by placing the integral assessment and plan components at the top of the note.

The American Journal of Accountable Care. 2017;5(1):29-34
Clinical notes are critically important to clinicians who must review these documents, synthesize data, and construct treatment plans for patients in a timely and efficient manner. Electronic health record (EHR) documentation has many recognized benefits, including legibility, accessibility, robust content, and simultaneous availability of clinical notes.1 However, some studies have reported that the quality of clinical documentation has deteriorated since the widespread adoption of EHRs.1-23 Reasons cited for this decline in quality include copy-forwarding of outdated or erroneous information, inclusion of standard phrases for regulatory purposes, and automatic insertion of large amounts of laboratory results that produce unnecessarily long notes. 

In 1997, Dr Larry Weed, founder of the traditional, problem-oriented SOAP (Subjective, Objective, Assessment, Plan) note, described the need for electronic tools that “reveal the actions and thought processes of providers.”4 Sixteen years later, the challenge to implement and structure EHRs that maintain the essential components of the problem-oriented note continues. 

In June 2013, the Associated Medical Directors of Information Systems proposed guiding principles for electronic documentation, including consideration of notes structured with the Assessment and Plan sections at the top and Subjective and Objective sections below (ie, APSO format). That same year, Lin et al reported that 83% of outpatient clinicians found the APSO note was faster to write than the traditional SOAP note, and 81% thought that it was easier to find data in APSO versus SOAP notes.5

Interestingly, there is a strong inverse correlation in the literature between successful EHR adoption and decreased time spent in clinical documentation tasks, such as finding and reviewing relevant information.6 Because readers can more quickly find the Assessment and Plan sections in APSO notes, we hypothesized that most clinicians would prefer to both read and write notes in APSO rather than SOAP format. To this end, we examined the degree of APSO adoption by inpatient and outpatient clinicians at a large, integrated healthcare delivery network.  We also studied clinician satisfaction with APSO notes from their perspectives as both note writers and readers.


Study Design

This study had 3 components: a retrospective review of outpatient APSO note adoption, a retrospective review of inpatient APSO note adoption, and a clinician satisfaction survey.


This study was conducted at University of Colorado (UC) Health, Aurora, Colorado, from January to July 2014. UC Health is a large, integrated health delivery network with 1 academic hospital, 4 community hospitals, and more than 100 outpatient clinics. All hospitals and outpatient clinics were studied. All sites were using an EHR system (EPIC Systems, version 2010, Verona, Wisconsin) and had implemented this EHR between February 2011 and September 2014.


For all components of our study, clinicians included attending academic and community physicians, medical residents, and advanced practice providers. All outpatient UC Health clinicians who wrote an office visit note on any patient in January 2014 were included in the outpatient chart review. Inpatient clinicians were only included in the study if they wrote a note on a patient who was discharged from any of our 5 hospitals on the day of the inpatient chart review in March 2014. For the satisfaction survey, 3170 clinicians with EHR access at UC Health received a link to the survey by e-mail. 

EHR Design

In the outpatient setting, clinicians have several options for creating EHR progress notes: the system-standard ambulatory note in APSO format; a clinic-specific or personalized note template, which can be custom-built in the SOAP format; or a blank, free-text note. As an enterprise, we do not mandate elements of note construction. The ability to insert dictated and transcribed text into a note is permitted for the History of Present Illness and the Assessment and Plan portions of outpatient notes. When clinicians dictate narrative in these sections, the transcribed text is inserted into a note template. Thus, it impossible to distinguish transcribed text from typed text in the outpatient notes during chart review.  

In the inpatient setting, a system-standard APSO format note is available for all clinicians, but personalized note templates can be used. Inpatient clinicians may also choose to dictate a full note when templates are not satisfactory. Our informatics and training teams actively promoted notes in APSO format throughout our rolling EHR deployment. Clinicians participating in this study had used the EHR for at least 3 months and up to 3 years at the time of the chart review and satisfaction survey.

Outpatient APSO Adoption

We performed a retrospective review of outpatient clinician notes in January 2014. The reviewers searched each clinician’s schedule and located the first day in January that the clinician saw patients in clinic, then they reviewed the first note written in that clinic session. This process was repeated for every outpatient clinician. Each note was classified as having been written in APSO, SOAP, or short format, with short format being defined as a note with less than 30 vertical lines on a computer display of 80 characters in width. Short note format was categorized separately because the reader typically does not have to scroll to review these brief notes efficiently. 

Inpatient APSO Adoption

We retrospectively reviewed the charts of patients discharged from all 5 hospitals in our system. For each hospital, we chose 1 day in the first 2 weeks of March 2014. We then reviewed the chart of every patient discharged in the prior 24 hours from that hospital. All notes written by clinicians in a selected patient chart were reviewed, including primary care, medical specialty, surgical specialty, and emergency department (ED) notes. We excluded patients discharged directly from the ED, operating rooms or perioperative areas, labor and delivery units, and procedural areas (including the cardiac catheterization, endoscopy, and bronchoscopy labs).

Using the EHR, we identified all clinician progress notes and included the first note per unique clinician. Notes were categorized as constructed in SOAP format, APSO format, or short format. We included 1 history and physical note per patient, as well as all progress notes and consult notes. We excluded the following: attending attestation statements, which addend the notes of medical residents; interval history and physicals written when there is a change in the patient care team; discharge summaries; and operative notes.  

Clinician Satisfaction Survey

We used an online, anonymous, password-protected questionnaire (via SurveyMonkey, Inc; Palo Alto, California) to assess clinician satisfaction with APSO notes. Lin et al originally described this survey in their 2013 study of APSO notes.5 Our modified survey was distributed to 3170 clinicians with EHR access at UC Health. We attempted to measure overall satisfaction with the APSO format, as well as perceived ease of construction and readability of APSO compared with SOAP notes. The survey was sent out by broadcast e-mail 3 times over a 2-week period in June 2014. 


Outpatient APSO Adoption

We reviewed 894 unique clinician notes from 101 outpatient clinics (Table 1). Of all notes reviewed, 94% were APSO (84.5%) or short (9.5%) format, and 6% were SOAP format (Table 2).

Inpatient APSO Adoption

A total of 1057 inpatient clinician notes were reviewed (Table 1). Of these, 791 (79%) were written in APSO (74%) or short format (5%), and 21% were in SOAP format. At the academic site, we reviewed 279 notes, 94% of which were in APSO (92%) or short format (2%). At the community hospitals, we reviewed 778 notes: 74% were written in APSO (69%) or short format (5%). Overall, 85% of primary care/hospitalists’, 77% of medical specialists’, 68% of surgeons’, and 94% of emergency medicine specialists’ notes were written in APSO or short format (Table 2). Finally, 61% of history and physical notes, 93% of daily progress notes, and 51% of consult notes were in APSO or short format (Table 3).

Inpatient Clinician Dictation

Of the 1057 notes reviewed from all inpatient sites, 15% were fully dictated. At the academic hospital, there were no dictated notes. At the community hospital, 25% (163/658) of all notes were fully dictated. We found only 4% (6/163 notes) of dictated notes were in APSO format. Fully dictated notes accounted for 71% of all consult notes, 47% of all histories and physicals, and 1% of all progress notes at the community hospitals.

Clinician Satisfaction Survey

A 20-question clinician satisfaction survey was sent to 3170 unique clinicians, including 1313 clinicians at the academic center and 1857 clinicians at community sites. We received 564 completed surveys for a response rate of 18%. Of those who responded: 54% were academic clinicians and 46% were community clinicians; 76% were physicians and 22% were advanced practice providers.

Writing APSO Notes

In our survey, 66.1% of clinicians reported writing “most” or “all” of their notes in APSO format, whereas 9.4% “frequently” write in APSO, and 15.8% never did. Overall, 80.6% of clinicians were “satisfied” or “very satisfied” with writing APSO notes. Eighty-four percent felt writing in APSO format was “easy” or “very easy” and 77.4% found the change from writing in SOAP to APSO format to be “easy” or “very easy.” In fact, 71.7% of clinicians said that the time it takes to construct a note in APSO is the same as the time it takes to construct a note in SOAP format (Table 4). 

Reading APSO Notes

In our survey, 70.6% of clinicians reported that it was “easier” or “much easier” to find clinically relevant data, 76.3% of clinicians reported it “faster “or “much faster” to browse through multiple EHR notes, and 67.7% of clinicians found it “easier” or “much easier” to follow clinical reasoning in APSO format compared with SOAP format. Overall, 68.1% of clinicians “preferred” or “strongly preferred” APSO over SOAP when reading clinical notes. Finally, 79.5% of clinicians were “satisfied” or “very satisfied” with APSO as note readers (Table 5). 


In this study, we demonstrate, for the first time, the successful, large-scale adoption of APSO notes across an integrated health delivery network consisting of academic, community, inpatient, and outpatient clinicians. APSO notes made up 87% of inpatient and outpatient notes across 5 hospitals and 100 clinics. Interestingly, of the 15% of inpatient notes that were dictated, only 4% were in APSO format. From their perspectives as both note writers and readers, 80% of clinicians were “satisfied” or “very satisfied” with the APSO note format. 

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