The Problem-Oriented Medical Synopsis

Abstract

The Problem-Oriented Medical Synopsis is a bedside worksheet that is constantly updated, to contain the current formulation of the patient's illness and the essential features of investigation and management. The ward interns or residents compile a list of problems when a patient is admitted to the hospital, with each problem specified by clinical criteria. The worksheet is progressively updated as a record of laboratory work ordered, results of tests, and management. Thus the Synopsis contains an up-to-date review of the current formulation of the case and is the essential document used for reviewing and discussing the case. When the patient is discharged from the hospital, the Synopsis becomes a problem-oriented summary of the case. This Synopsis has been compiled for all inpatients of a 27-bed medical ward during a 2-year period and is an aid in patient care, teaching, research, hospital administration, and computer processing of medical records.