The clinical data collection process starts when a patient starts telling a physician about his or her condition. This is known as the patient history, and since it is not observed directly by the physician, but instead recounted by the patient, the patient’s story is known as subjective information. In contrast, objective information comes from the physician and consists of the physician's own observations about the patient, from the physical examination, lab tests, and imaging studies, to other diagnostic procedures. Together, the subjective and objective information makes up the clinical note.
There are several types of clinical notes used in healthcare. The history and physical (H&P) is the most thorough and comprehensive clinical note. It is usually obtained when an outpatient physician sees a patient for the first time, or when a patient is first admitted to the hospital. Collecting all the data from the patient and typing up the H&P on the hospital computer may take a total of 1-2 hours for a single patient. Usually, an H&P is only done once per physician/hospital admission. For successive outpatient visits, or an inpatient admission lasting several days, briefer clinical notes are compiled. These are termed progress notes, or SOAP notes (SOAP stands for subjective, objective, assessment, and plan). In these notes, the focus is on events that have occurred since the initial H&P or the previous progress note.
Before patient data appears in your database, it makes a long journey, starting from the patient history as interpreted by the physician team. The patient story is combined with other pieces of information from different clinical departments (for example, laboratory, imaging) to form the electronic health record (EHR). When the hospital wants to make the data available to a third party for further analysis, it typically releases the data to the cloud in a database format.
Once the data is captured in a database system, the analytics professional can then use a variety of tools to visualize, pivot, analyze, and build predictive models:
In the following subsections, we will describe the important aspects of these two types of clinical notes.