The evolution of office notes and the electronic medical record: The CAPS note.
Where this comes from
- Record sourced from PubMed, PMID 27399867.
- Also identified by DOI 10.3949/ccjm.83a.14191.
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Abstract
The advent of the electronic medical record (EMR) combined with an expansion of information required by medicolegal and billing departments has transformed the progress note from a succinct note into an often unwieldy data-dump unable to concisely convey the physician's medical reasoning. We describe a new note format--CAPS, which stands for concern, assessment, plan, and supporting data--to streamline the communication of the patient's problem, the practitioner's assessment and plan, and the medical reasoning to support the plan.
Medical subject headings
- Electronic Health Records