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Practice of medicine

Posted on:3/24/2006
The practice of medicine combines both science and art. Science and technology are the evidence base for many clinical problems for the general population at large.



The practice of medicine combines both science and art. Science and technology are the evidence base for many clinical problems for the general population at large. The art of medicine is the application of this medical knowledge in combination with intuition and clinical judgment to determine the proper diagnoses and treatment plan for each unique patient and to treat the patient accordingly.

Central to medicine is the patient-doctor relationship established when a person with a health concern or problem seeks the help of a physician (i.e. the medical encounter). Other health professionals similarly establish a relationship with a patient and may perform interventions from their perspective, e.g. nurses, radiographers and therapists.

As part of the medical encounter, the doctor needs to:

1) develop a relationship with the patient
2) gather data (medical history and physical examination combined with laboratory or imaging studies)
3) analyze and synthesize that data (assessment and/or differential diagnosis), and then
4) develop a treatment plan (further testing, therapy, watchful observation, referral and follow-up)
5) treat the patient accordingly
6) assess the progress of treatment and alter the plan as necessary.

The medical encounter is documented in a medical record, which is a legal document in many jurisdictions. One method that is used is called the problem-oriented medical record (POMR), which includes a problem list of diagnoses and a "SOAP" method of documentation for each visit:

S - Subjective, the medical history of the problem from the point-of-view of the patient.
O - Objective, the physical examination and any laboratory or imaging studies.
A - Assessment, is the medical decision-making process including the differential diagnoses and most probable diagnoses.
P - Plan, the way resolve the problem and monitor progress


 


  
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