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Patient-Reported Use of the After Visit Summary in a Primary Care Internal Medicine Practice

Sarita Pathak1,2, Gregory Summerville1, Celia P Kaplan1,2

  • 1Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA, USA.

Journal of Patient Experience
|December 9, 2020
PubMed

Keywords:
communicationhealth literacypatient educationquality improvement

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SBAR is an effective communication tool used by healthcare professionals to communicate patient information accurately. SBAR stands for Situation, Background, Assessment, and Recommendation. For a better understanding, an example is given below.
SBAR Report from a Nurse to a Health Care Provider
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The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.
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Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
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