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Structure of consultation records

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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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