The evolution of office notes and the electronic medical record: The CAPS note

Article Figures & Data

TABLE 1

Comparison of medical note formats

Format	Structure
SOAP	Subjective information Chief concern History of present illness Patient’s medical, surgical, family, social history Objective information Physical examination Laboratory and test data Assessment Plan
APSO	Assessment Plan Subjective information (as above) Objective information (as above)
CAPS	Concern Patient’s chief concern History of present illness, injury Assessment Diagnosis with clinical reasoning Plan Itemized list of actions to address patient’s concerns and condition Supporting information (objective and subjective) Vital signs and physical examination Results of laboratory, radiographic, other tests Comprehensive review of systems Patient’s medical, surgical, family, social history Current medications Allergies