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2016 ; 2016
(ä): 763-771
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Toward Medical Documentation That Enhances Situational Awareness Learning
#MMPMID28269872
Lenert LA
AMIA Annu Symp Proc
2016[]; 2016
(ä): 763-771
PMID28269872
show ga
The purpose of writing medical notes in a computer system goes beyond
documentation for medical-legal purposes or billing. The structure of
documentation is a checklist that serves as a cognitive aid and a potential index
to retrieve information for learning from the record. For the past 50 years, one
of the primary organizing structures for physicians' clinical documentation have
been the SOAP note (Subjective, Objective, Assessment, Plan). The cognitive check
list is well-suited to differential diagnosis but may not support detection of
changes in systems and/or learning from cases. We describe an alternative
cognitive checklist called the OODA Loop (Observe, Orient, Decide, Act. Through
incorporation of projections of anticipated course events with and without
treatment and by making "Decisions" an explicit category of documentation in the
medical record in the context of a variable temporal cycle for observations, OODA
may enhance opportunities to learn from clinical care.