An intelligent hypermedia system for generating progress notes and physician reminders

摘要

This paper describes an automated Progress Note System running in the diabetic clinic of the VA Medical Center in North Chicago, Illinois. The organization of the authors progress notes is based on Weed's problem-orientated approach to medical records (L. Weed, 1970). The system helps the physician to formulate a problem list and then, for each problem, it assists in the collection of subjective and objective data and the generation of assessments and plans. The Progress Note System uses data downloaded from the VA's MUMPS database and it interfaces to the Oracle database maintained for research purposes by the diabetes clinic. The reminders are based on the American Diabetes Association's position statement on standards of medical care.