Recording, Retrieval and Review of Medical Data by Physician-Computer Interaction

Abstract

A computer-based medical-record system depending on a dialogue between the physician and a computer-controlled display screen has been designed to enter progress notes. A limited vocabulary in a structured format is used. Flexibility is provided in that the user can branch selectively to particular topics, or make comments by keyboard or dictation. Notes entered into this system in a hypertension clinic have been more legible, better organized and more complete than those formerly recorded. Notes comparable in size to those written by hand have been generated more rapidly, and physician acceptance has been high. Automated production of summaries, selective review of a patient's problems and research retrieval capabilities are features of this system.