Toward Medical Documentation That Enhances Situational Awareness Learning.

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.