Toward Medical Documentation That Enhances Situational Awareness Learning

Area of Science:

• Medical Informatics
• Clinical Documentation
• Cognitive Science

Background:

• Physician clinical documentation has historically relied on the SOAP (Subjective, Objective, Assessment, Plan) note structure for over 50 years.
• While effective for differential diagnosis, the SOAP note's checklist format may limit the detection of systemic changes and learning from patient cases.
• Medical notes serve as cognitive aids and indices for information retrieval and learning.

Purpose of the Study:

• To introduce and describe the OODA Loop (Observe, Orient, Decide, Act) as an alternative cognitive checklist for clinical documentation.
• To explore how the OODA Loop can enhance learning from clinical care compared to traditional methods.
• To highlight the potential of incorporating decision-making and future event projections into medical records.

Main Methods:

• Describing the OODA Loop framework as a cognitive checklist for medical documentation.
• Proposing the integration of anticipated clinical course events (with and without treatment) into the documentation process.
• Emphasizing "Decisions" as an explicit documentation category within a variable temporal observation cycle.

Main Results:

• The OODA Loop offers a novel structure for clinical documentation.
• Explicitly including "Decisions" and future projections may facilitate a deeper analysis of clinical events.
• The temporal cycling of observations within the OODA framework can support learning.

Conclusions:

• The OODA Loop (Observe, Orient, Decide, Act) presents a potentially superior cognitive checklist for medical documentation compared to the SOAP note.
• This alternative structure may enhance physicians' ability to detect changes and learn from clinical experiences.
• Integrating decision-making and predictive elements into medical records can improve clinical learning and care quality.