RT Journal Article
SR Electronic
T1 The evolution of office notes and the electronic medical record: The CAPS note
JF Cleveland Clinic Journal of Medicine
JO Cleve Clin J Med
FD Cleveland Clinic
SP 542
OP 544
DO 10.3949/ccjm.83a.14191
VO 83
IS 7
A1 Joseph F. Styron
A1 Peter J. Evans
YR 2016
UL http://www.ccjm.org/content/83/7/542.abstract
AB 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.