Intelligent Medical Record--entry (IMR-E) - PubMed (original) (raw)

. 1993 Aug;17(3-4):139-51.

doi: 10.1007/BF00996938.

Affiliations

Intelligent Medical Record--entry (IMR-E)

D Trace et al. J Med Syst. 1993 Aug.

Abstract

This paper describes an automated medical record designed to allow providers to enter patient data at the point of care. The system runs on PCs and Macintoshes and uses a graphical user interface and object-oriented programming to take advantage of current mouse and pen technologies. The provider acquires all relevant patient data by pointing and clicking at selections on input screens, many of which contain anatomical drawings to help the provider quickly and accurately describe patient findings. The system also generates a grammatically correct progress note using the problem-oriented structure. Furthermore, items identified in the assessment and plans portion of the program can be ported to expert systems for medical decisions assistance or to billing systems. The system allows the provider to obtain the necessary information on a focused patient visit in less than 5 min or to enter a complete history and physical.

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References

    1. JAMA. 1968 Aug 19;205(8):571-6 - PubMed
    1. Med Care. 1982 Jan;20(1):63-74 - PubMed
    1. Am J Public Health. 1979 Jul;69(7):680-9 - PubMed
    1. Ann Intern Med. 1973 May;78(5):751-62 - PubMed
    1. J Chronic Dis. 1986;39(11):889-96 - PubMed

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