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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.

Published on Monday, November 11, 2019 by Nicholas O