A structured documentation format utilized in healthcare, usually in digital well being information, organizes scientific notes effectively. This format facilitates clear and concise communication amongst healthcare professionals, using classes for Subjective (patient-reported data), Goal (clinician’s observations), Evaluation (prognosis), and Plan (therapy technique). An instance might embody a affected person reporting a headache (subjective), the doctor noting elevated blood strain (goal), diagnosing hypertension (evaluation), and prescribing remedy (plan).
Standardized documentation enhances affected person security by decreasing errors and enhancing care coordination. The constant construction ensures important data 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 file within the Sixties, which laid the groundwork for this format’s growth as a sensible software of the tactic.
