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hello I'm Eric strong from strong
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medicine and today I'll be continuing
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this series on medical presentations and
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written notes by discussing the EAP
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format which is specifically appropriate
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for inpatient medicine I've already
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covered the medical hmp and soap formats
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including two example presentations of
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each this video will build on those and
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we'll continue to use the same two cases
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notably although EAP is a different
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format than soap many the same general
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principles apply so if you're unfamiliar
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with soap you may want to start there
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first and then come back to this
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afterwards in extreme brief though both
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soap and the similar format and the
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EAP format are ways to update teams
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about a patient status on a daily basis
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I'll address this a little more near the
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end of this video but this Bend diagram
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is just a little misleading in the sense
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that it is conflating progress notes
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which are part of the written medical
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record with oral presentations for
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example while the Appo format is almost
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solely advocated as a format for the
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written notes the EAP is primarily
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advocated as a format for the oral
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presentation though personally I think
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EAP works well for both written and
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verbal
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communication because soap is the near
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Universal standard I'll be comparing and
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contrasting soap and AP throughout this
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talk to remind you here is the soap
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format soap stands for subjective
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objective meaning the exam and test
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results assessment and plan the last of
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which is presented in the form of a
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problem list there are also three
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sections that aren't represented by the
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acronym the ID line colloquially
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referred to as the oneliner which
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functions as a reminder of who the
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patient is the overnight events in which
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overnight really means any and all
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events and the full inpatient medication
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list which is typically only included in
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the written notes not the oral
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presentation while the soap has been the
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standard format for impatient medical
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documentation and oral presentations for
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decades it has one huge shortcoming it
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necessarily separates the data located
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in the subjective and objective sections
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from the clinical reasoning thought
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process present in the assessment and
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the plan this makes it harder for a
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reader or listener to follow another
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clinician's train of thought because
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it's not always clear what the data is
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that the clinician has used to draw
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their conclusions this is particularly
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true when the soap note or the
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presentation includes all of the
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objective data within the objective
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section that is literally every single
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exam finding and test result since the
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act of limiting the inclusion of data to
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only what's relevant for that patient
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even if it's still partitioned within a
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separate objective section would still
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reveal a little of the collis's
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reasoning and thought
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process the primary purpose of the EAP
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format is to address this shortcoming
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here's what the format looks like the ID
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line and event section is more or less
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the same then immediately follows the
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overall Global assessment of the
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patient's condition in including a
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statement as to whether the patient is
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improving worsening or remaining
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unchanged then we jump right into the
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problem list but this time each
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individual problem has a mini soap of
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its own in which the subjective and
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objective sections of each mini soap
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only contains the symptoms exam findings
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and test data that's relevant to that
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particular
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problem let's look more closely at what
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the differences between soap and EAP
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look like within a written
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note so here will be a typical soap note
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in
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2024 it starts with the ID line which
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more often than not is actually a
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rambling uh list of past or chronic
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medical problems that are of minimal
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relevance to the current admission then
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the list of major events since
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admission then the subjective line
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indicating how the patient is feeling
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that
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morning then the near useless objective
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section in which vitals are autop
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populated and never include the vitals
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at the time of the clinician's own
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actual bedside exam a copy and pasted
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version of the exam findings from the
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previous day with few if any edits then
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a long list of autop populated Labs many
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of which are outdated or irrelevant and
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then Imaging results with the report
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also autopop populated or manually copi
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and pasted in its entirety as if the
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full report wasn't just a click away on
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the
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EMR the assessment is usually
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unhelpfully the same as the ID line and
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finally comes a problem list which is
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really just a list of plan items
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separated by
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problem in contrast here is the ideal
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EAP note first the ID line is concise
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using the format previously covered in
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this series of age plus gender plus
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highly relevant medical and social
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history plus the primary diagnosis or
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the chief complaint and or clinical
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syndrome if the diagnosis has not yet
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been made the event section is the
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same the assessment is relatively brief
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but is updated daily and is thoughtful
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despite its
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brevity then the problem list including
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only active problems or those which have
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resolved within the last 24 hours just
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to acknowledge that resolution and the
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list should be rep prioritized daily
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under problem X we have the subjective
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symptoms relevant for X manually entered
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exam findings relevant for X relevant
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labs and imaging for x a oneline
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assessment specifically for x and a plan
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for X then for problem y we go through
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the same list for problem Z and so on
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and so forth notably not every component
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included here will be relevant to every
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problem for example hypokalemia is
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usually an incidental test result with
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no symptoms or exam findings or for
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patient experiencing migraine headaches
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in the hospital there are usually no
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relevant lab tests or relevant
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Imaging what are the advantages of the
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EAP format as already discussed the
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format more closely resembles how
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clinicians think about problems or at
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least how they probably should be
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thinking about Problems by directly
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linking the data to the action the
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clinician stop process is also more
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clear to others in addition although
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it's not the primary point the EAP
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format also allows notes and
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presentations to be more streamlined
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after some practice and that's because
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as I often see with interns and students
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using the soap format for presentations
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they will mention particular data in the
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subjective or objective sections and
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then they'll talk about something else
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in the patient's uh case for you know 3
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four 5 minutes whatever and then they'll
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finally come back to the problem that
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was relevant to that previous data but
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now because of all the interpost
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information they have to mention it
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again to remind everyone of it in other
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words there's some redundancy in what's
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presented redundancy is not huge it
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might only amount to 30 seconds total
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per patient but that can be 5 to 10
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minutes each morning or an entire hour
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of redundant discussion over the course
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of a week that you know I wouldn't mind
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having back and I think many other uh
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attendings res would feel the same way
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likewise for written notes similar
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redundancy adds to the overall length
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making the most important nuggets of
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information harder to
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find however there are also some
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disadvantages of the EAP format that I
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don't want to gloss over first it
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requires higher initial cognitive load
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for house staff and students if trainees
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are organizing information in
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preparation for an oral presentation
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it's going to be more automatic to
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organize it into buckets of symptoms
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exam findings and Labs then it will be
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to organize it into buckets of problem X
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problem Y and problem
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Z there's also a problem with the fact
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that in order to Define and prioritize
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the problems we need the data beforehand
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which is why the EAP format really can't
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be used for the hmp or any other initial
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communication about a new
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patient another disadvantage is that the
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EAP format necessarily excludes data
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that's not relevant to an active problem
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so attending to rely on the oral
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presentation to write down you know
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every single new lab result they'll need
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to get that data directly from the EMR
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themselves now luckily the practice of
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attendings asking interns to read off
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long lists of lab results seems much
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less prevalent now than when I was an
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intern but I can still imagine some old
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school folks who still shake their fist
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and mutter under the breath at the very
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idea of an EMR
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they still might be out there doing this
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and the EMA uh the EAP format is not
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consistent with that presentation
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expectation of
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theirs next some data might not cleanly
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fit into a discrete problem for example
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how much a patient is eating or sleeping
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or how much they're working with PT and
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OT these things don't always map to
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something on the problem list and last
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the EAP format has the disadvantage of
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being new and for all the lip service
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medical schools and other academic
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institutions might give about being
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Progressive and leading Healthcare into
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the
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future individual people hate changing
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how they practice medicine so many
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faculty are going to be resistant to
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using a new format whether it's EAP or
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anything else you come up with and of
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course this format's not really taught
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in schools when I was in relatively new
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attending about 15 years ago I tried to
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enact the EAP format within my team's
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rounds uh and I gave a talk on why it
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was better which included many of the
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same points as this video the interns
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and students I worked with they all
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seemed to agree that it sounded better
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but when it came time to actually giving
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oral presentations during rounds they
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very consistently fell back on the soap
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format despite me reminding them of EAP
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every day because soap was more
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ingrained and they could do it with less
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conscious thought you know I compared
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you might make is like it's like a
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basketball player who has a terrible
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shooting form he may recognize his form
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isn't great he may deliberately uh
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practice with a coach to work on the
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form and he may honestly want to use
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better form in a game but during game
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time itself he's still going to default
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back to what he's been doing for years
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because it feels
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natural after a few months of me pushing
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the EAP format I did reluctantly give up
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but that was nearly a generation ago and
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maybe it's an idea that medicine is now
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ready
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for finally pre-existing EMR templates
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are designed in soap format and current
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emrs they can't autop populate data in
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EAP
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format this brings me to two final
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points that I alluded to at the
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beginning first there is not a specific
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requirement that oral presentations and
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written notes must follow the same
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format as one another it is a perfectly
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acceptable position position to say that
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EAP should be used for oral
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presentations while soap should be used
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for
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notes now I personally I think that's
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hard for trainees particularly students
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who rely on using the printed written
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note as a reference during their oral
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presentation but there may be sub
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situations in which this is reasonable
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for example as mentioned current emrs
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can't do EAP templates because they are
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based on problem lists and emrs are not
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currently intelligent enough
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to predict what a clinician's problem
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list for a patient is going to look like
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however AI integrated into emrs May fix
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this problem by predicting the problem
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list and pre-writing a first draft EAP
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style note EAP style notes pulling in
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the data that the AI predicts is
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relevant for each problem substantially
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improving efficiency now we aren't there
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yet in 2024 despite what some em uh EMR
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vendors might claim at medical
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conferences but I think we're close and
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when an when an AI reaches the point
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where it can link the most relevant data
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for each problem within an accurately
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predicted problem list within a
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pre-written progress notes it will be
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hard to ignore the fact that the EAP
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format is fundamentally Superior to soap
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despite how uncommon it currently is to
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see used in practice
