The medical record is a data and information machine. The lifelong GP record had some basic universal attributes:
- A problem sheet - listing the past and present "disease2 issues that affected the patient.
- A simple structure for undertaking and recording a consultation - SOAP, Subjective, Objective, Analysis and plan.
- A coordinated method of managing preventive, presenting, proactive, and past problems - the 4 "P"s. based on a clinical method -
- history taking, Clinical examination, tests, initial diagnosis, initial care plan, discussion and agreement with patient, implementation, follow up if necessary.
It is also important to "know and record the patient" - *Sir William Osler <https://www.google.com/search?kgmid=%2Fm%2F012mn4&q=Sir+William+Osler>* famously stated: “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.
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HIFA profile: Richard Fitton is a retired family doctor - GP. Professional interests: Health literacy, patient partnership of trust and implementation of healthcare with professionals, family and public involvement in the prevention of modern lifestyle diseases, patients using access to professional records to overcome confidentiality barriers to care, patients as part of the policing of the use of their patient data Email address: richardpeterfitton7 AT gmail.com