In "The Language of Medical Case Histories," Dr. Donnelly advances the correct premise that the very descriptives we use determine the interpretation and valuation we apply to that which is being described [1].

The term "denies" does put a burden of proof on the patient. "Subjective" is sterile and does imply a certain "second-class" quality in comparison to the unassailable "objective" of the physician's input. HOAP may be viewed as a somewhat more useful (dare I say hopeful) formulation. As a believer in taking parallel "illness behavior" and "biomedical model" approaches to the understanding and management of patient, I thought that HOAP did not go far enough.

"History" is too limited because it seems to deal only with "chief complaint"; it does not encourage either the use of the patient's voice or an expansion of input to deal with life-issues. "Observations" is certainly an improvement on "Objective." "Assessment" implies decision making that may not be appropriate. "Plan" is very action-oriented; perhaps a term is needed that adds reflection to action.

As a lover of acronyms, I would like to offer an alternative to SOAP/HOAP: AXIS.

"A" is for anamnesis: the recollections of the patient, not limited to the "chief complaint." By focusing on the memory and recollections of the patient, we emphasize the use of the patient's own words and do not devalue or circumvent the impressions expressed [2].

"X" is for examinations: the physical and laboratory examinations, whose results are open to interpretation and thus not necessarily objective.

"I" is for integration: the process whereby the care provider coordinates the patient's perception of his or her illness ("illness behavior"), the possible underlying disease process (as represented in physical examination and laboratory testing results-the "biomedical model"), and other data into an interim understanding. Integration is meant to emphasize the two parallel views: illness and disease, experience and organ pathology.

"S" is for strategies, not explicitly limited to plans. This can be used to focus trainees on various issues, including, but not limited to, means of gaining insights into the patient's understanding of his or her illness (for example, "illness meaning," "catastrophizing" [3]); need for advanced directives; do-not-resuscitate status; social support systems and possible need for placement; and the diagnostic tests and therapies to be used.

AXIS emphasizes the biopsychosocial approach [4], focusing on a nonjudgmental hearing of the patient's recall and the patient's experience of the illness. For this reason, SOAP/HOAP might best be modified, perhaps to demonstrate that patient evaluation does in fact revolve about a somewhat different axis than was defined nearly 30 years ago [5].