Operative Note

Problem Oriented Charting (POC) is an approach to clinical documentation that allows progress to be described in terms of the health conditions listed in a patient's Problem List, rather than in terms of encounters or visits. POC is particularly attractive for inpatient charting. Clinicians can better track treatments and trends for multiple issues over time. They can also more find information about the evolution of individual problems.

POC is most efficient when started at the beginning of an inpatient encounter, using purpose-built documentation tools before composing any histories, consults, notes or summaries. This section explains how to get the most out of the POC Operative Note documentation template in Connect Care.