The record revolutionary
Larry Weed is, in many ways, the father of the Problem Orientated Medical Record and “SOAP” notes (Situation, Observation, Assessment and Plan).
Have a look at this 1971 lecture on “The Grand Round”. Its depressingly serious yet delivered with wonderful, if a little confrontational, humour. His use of the term “database” for a manila folder case-note is a little disconcerting for the 21st century, if wonderfully accurate
What did I take away from this?
- The prevalence of disorderly care records remains harmful to health
- Computers need to help, not hinder
- The case note remains the central repository of knowledge and remains impenetrable to most clinicians
- The central organising structure, the problem list, drives the definition of the plan
- The future is described in the plan. It may not be an accurate prediction, but its the best we have
- If we don't record it or can't find it, we can't audit it and can't say we made a difference.
Thanks to Leon Bamford for sharing this video with me.
Monday, November 11, 2019