Still many physicians keep careful records, following the habits acquired in medical school. Larry Weed presented a formal structure to collect medical records. O A set of Objective diagnostic tests. A The Assessment , based on the subjective and objective information. The final entry is the plan, including a the presecribed treatment and prognosis, a statement of the expected patient state at the next planned encounter.
Any new problem gets a new problem number for further reference.
For a follow-up visit the earlier problem statement should be referenced. Sometimes subsequent tests may show that the perceived problem was actually a result of a pre-existing problem, or that one problem had two causes. Then problem assignments can be merged or split. Having a prognosis enables feedback to occur about one's prognosis and plans. Without being explicit about the expectations for treatmet it is difficult assess if the plan is successful.