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Structure of consultation records

Authoring team

Consultation records include:

  • a chronological record of all surgery, visit and telephone encounters

  • a structured clinical record which may use:

  • Problem Orientated Medical Records (POMR) with problem and subproblem headings to which subsidiary records can be attached

  • Subjective, Objective, Assessment and Plan subheadings for history, findings, diagnosis and management (SOAP)

  • computer systems which can display records in a multitude of ways, selected by allocated priorities, by automatic data categories or by coding of data

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The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions.

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