A&P blocks are combined with subjective & objective blocks to create a POC progress note. They are also pulled in to any of the "advanced" summative documentation templates (e.g., admitting history, discharge summary, consult). Only those A&P blocks that were changed since the last note are pulled into the next note, and any prior A&P note is always copied forward to a new A&P note. In this way, clinicians can keep documentation focused on new or updated A&Ps, while saving time by having any prior planning text available to edit.
Typically, A&P blocks are created or revised after creation of a Subjective & Objective note. New or revised A&P blocks remain in "current" status, available for editing by any member of the clinical team (for the specialty selected in the POC navigator), until a new progress or summative note is created.
- When no current A&P block exists for a problem, the POC problem list indicates that an A&P block can be started.
- When an A&P block has been started but not yet locked into a progress note, then the problem A&P area indicates that a block exists and can be edited.
- As soon as a POC progress note or summative note is signed, it "locks in" the last A&P note. The problem A&P area changes to indicate that a new note can be created. The last signed note is available for quick review. It is also possible to review all past A&P notes about the same problem.
All A&P text block editors support dictation and SmartStuff so that SmartPhrases and SmartText, for example, can be used to speed text generation. The content of the last problem and specialty-specific A&P text block is automatically copied forward.
A&P Format and Style Recommendations
The best A&P notes are unique (do not replicate information elsewhere in the chart or destination note), succinct (keep to a single paragraph) and adhere to a consistent style that is easy to read. We recommend that the assessment be entered as plain text and the plan as bulleted points (see image above). The bullet-list toolbar item can be added (if not already present) by using the "Modify Toolbar" menu item in the A&P text editor.
