Lenert Leslie A
Biomedical Informatics Center, Medical University of South Carolina, Charleston, SC, USA.
AMIA Annu Symp Proc. 2017 Feb 10;2016:763-771. eCollection 2016.
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.
在计算机系统中撰写医学记录的目的不仅仅是出于医疗法律目的或计费的文档记录。文档结构是一个清单，可作为认知辅助工具，并作为从记录中检索信息以供学习的潜在索引。在过去的50年里，医生临床文档的主要组织结构之一是SOAP记录（主观、客观、评估、计划）。这种认知清单非常适合鉴别诊断，但可能不支持检测系统变化和/或从病例中学习。我们描述了一种名为OODA循环（观察、定位、决策、行动）的替代认知清单。通过纳入有无治疗情况下预期病程事件的预测，并通过在可变时间周期的观察背景下将“决策”作为病历文档中的一个明确类别，OODA可能会增加从临床护理中学习的机会。
