title: The evolution of office notes and the electronic medical record: The CAPS note.
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.
authors.affiliation: Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA. E-mail: styronj@ccf.org.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Styron
authors.affiliation: Director, Upper Extremity Center, Cleveland Combined Hand Fellowship, and Peripheral Nerve Center, Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Evans
mesh_terms: D057286:Electronic Health Records; D005568:Forms and Records Control; D006801:Humans