A structured documentation format utilized in healthcare, sometimes in digital well being data, 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 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 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 utility of the strategy.
