The Clinical Synopsis*

Summary: We have devised the problem oriented clinical synopsis to provide a continuously updated and formalised record of patient management in a teaching hospital. The synopsis is de-signed for explicit recording of evidence used in making decisions on diagnosis, investigation or treatment and so facilitates communication and quality control in the ward environment. When the patient is ready for discharge the synopsis automatically provides a final case summary for despatch to the referring doctor. For 554 patients admitted to a medical ward over a twelve month period, the synopsis was compiled on a pre-printed form** divided into eleven columns. A list of provisional diagnoses (or unexplained problems) was entered in a column down the left of the synopsis form. Contributory history, signs and investigations and decisions on treatment were recorded in appropriate columns across the page. Subsequently the synopsis Before discharge, a recommended management was recorded against each diagnosis and a final discharge opinion added. The synopsis data were entered at a computer terminal and processed by a programme which printed out a formalised case summary.