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In the previous post ‘how should we define Electronic Medical Records?’, I proposed the adoption of a restrictive definition for EMRs. In the this post I will present Wyatt (1994) view of what data constitute an EMR.

Wyatt (1994) presents a simplistic and yet very practical categorization of data that is stored in EMRs.  This view should hold true with future advancements in medicine. He proposes to modify Weed’s (1968) SOAP clinical data classification. For those not familiar to SOAP classification, S stands for subjective, O for objective, A for assessment and P for plan.

Wyatt’s (1994) classification:

1. Patient findings. This includes Weed’s subjective and objective categories. Wyatt correctly identifies the difficulty of drawing the line between subjective and objective patient data. Patient findings will include patient’s medical history, physical examination findings and investigations’ results.

2. Hypotheses. This includes clinician assessment and plan. Wyatt’s intention to group these two categories into one, though practical when writing and presenting them, (each point in a clinician’s plan will be based on an assessment statement) seems confusing. My feeling, you will always need to define hypotheses by its parts: assessment and plan. Therefore, maintaining Weeds classification seems more practical.

3. Actions. This will constitute a description of the parts of the plan that have been carried out. For me, it has always been confusing how to place actions into Weed’s classification.

4. Identifiers. This would be an agreed upon document identification that can connect the document to the correct patient. Examples would be patient name, data of birth, demographics, identity numbers and social security numbers.

5. Modifiers. These are as who recorded the data and when. Wyatt includes other modifiers as the severity and the certainty of clinicians assessment.

In the coming posts, I will present how is this information is used by clinicians and how can we present them in EMRs.

Weed, L.L., 1968. Medical records that guide and teach. New England Journal of Medicine, vol. 278, pp. 652-657 and pp. 593-600

Wyatt, J.C., 1994. Clinical data systems, Part 1: Data and medical records. Lancet, 344(8936), 1543-7.