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The evolution of office notes and the electronic medical record: The CAPS note
Joseph F Styron1, Peter J Evans2
1Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA.
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.
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