A structured documentation format utilized in healthcare, usually in digital well being information, 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 may embody 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 enhancing care coordination. The constant construction ensures crucial info is quickly accessible, enabling environment friendly decision-making and streamlined communication. Historic context traces again to Dr. Lawrence Weed’s introduction of the problem-oriented medical report within the Nineteen Sixties, which laid the groundwork for this format’s growth as a sensible software of the tactic.
