Electronic medical record progress notes: (thoughts by Malcolm Ireland)

GP consultations are not always well structured, and are extremely variable in their content.  Paper notes cope well with this, with the use
of arrows, underlines, colour, links, diagrams etc which are understood by the writer, and
 often by other people reading the notes.  This totally flexible and visual way of recording,
although not impossible with electronic notes, is extremely difficult to implement.

Even with paper notes, attempts have been made to  force consistent structure in notes.
When I was a student, hospital notes included presenting problem (PP), history of presenting illness (HPI), 
past history (PH), systems review (SR), social history etc.  There was often discussion as to what 
should be included in HPI and PH and SR when there was often overlap.  The hospital method worked fairly 
well (and still does), but does not translate well to general practice.  Then came SOAP - where the notes 
were divided into subjective, objective, assessment and plan.  This was an improvement for GPs,
 but still only fits a proportion of visits, and there is argument as to what fits where (eg, when a detailed history
is "extracted" with some difficulty from the patient, is that S or O?  It also fails with brief consultations
 such as BP check wth repeat prescription, or when the patient's presentation and the GP's reason for seeing them
are different.  It does not fit well with current preventive strategies.

I did a small study of GP notes some years ago, and learned that GPs recorded fairly consistently why the patient came (?S),
and what was done (?P).  The processing in the middle (O and A) was very inconsistent.  Whether
this is good or bad is not the question - it is reality.

Can I describe a generic consultation?
	Why did the patient come (S, or PP, or because I called them back, or part of a
structured multi-visit plan, or for routine preventive care etc).
	What did they tell me (S, PP, HPI), what did I extract (S,O,HPI,PH,SR), what did I find on examination,
(O - remembering that examination is often not done, and that it often adds very little to the "history").
	What was I thinking (A) - do I actually record this? Am I thinking I don't have a clue,
but I don't think its serious and will see what happens over the next few days.  Do I record my ignorance?
	What did I do?  Tests (expecting abnormal or normal, or just filling in time?), advice, wait,
prescribe, not finish this episode and get them back.

I haven't discussed the problem oriented medical record.  We're supposed to  allocate a problem  (or more) 
to every visit), and know if they're curent, resolved, continuing etc.  Anyone who has tried to do
this knows haw difficult it is.  What do you do with the patient who doesn't seem to know why they 
came, who you can't work out why they came, but who leaves happy with the consultation and 
appears to have had some need satisfied?

In summary, any structured format works much of the time, but there are many exceptions when it 
fails.  The tendency is to "fill in the boxes", even though its not exactly true.  The only truly safe method
 to capture the content of a consultation is to use unstructured English (or any other language).

I guess I'm saying no matter what you do, it won't work for anyone all of the time, and for some
people will never work, but anything is better than the current situation.