A structured documentation format utilized in healthcare, usually 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 (remedy technique). An instance might embrace a affected person reporting a headache (subjective), the doctor noting elevated blood stress (goal), diagnosing hypertension (evaluation), and prescribing treatment (plan).
Standardized documentation enhances affected person security by lowering errors and enhancing care coordination. The constant construction ensures essential 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 Nineteen Sixties, which laid the groundwork for this format’s growth as a sensible utility of the tactic.
