A structured documentation format used in healthcare, typically in electronic health records, organizes clinical notes efficiently. This format facilitates clear and concise communication among healthcare professionals, utilizing categories for Subjective (patient-reported information), Objective (clinician’s observations), Assessment (diagnosis), and Plan (treatment strategy). An example could include a patient reporting a headache (subjective), the physician noting elevated blood pressure (objective), diagnosing hypertension (assessment), and prescribing medication (plan).
Standardized documentation enhances patient safety by reducing errors and improving care coordination. The consistent structure ensures critical information is readily accessible, enabling efficient decision-making and streamlined communication. Historical context traces back to Dr. Lawrence Weed’s introduction of the problem-oriented medical record in the 1960s, which laid the groundwork for this format’s development as a practical application of the method.
