A structured documentation format utilized in healthcare, sometimes in digital well being data, organizes medical notes effectively. This format facilitates clear and concise communication amongst healthcare professionals, using classes for Subjective (patient-reported info), Goal (clinician’s observations), Evaluation (analysis), and Plan (therapy technique). An instance may embrace a affected person reporting a headache (subjective), the doctor noting elevated blood strain (goal), diagnosing hypertension (evaluation), and prescribing medicine (plan).
Standardized documentation enhances affected person security by decreasing errors and bettering care coordination. The constant construction ensures crucial info is instantly accessible, enabling environment friendly decision-making and streamlined communication. Historic context traces again to Dr. Lawrence Weed’s introduction of the problem-oriented medical document within the Sixties, which laid the groundwork for this format’s growth as a sensible utility of the strategy.
