The future usage of automated medical records in part depends upon the development of a user acceptable format for the storage of subjective and physical data which allows this data to be clinically usable, while remaining formalized to the degree that the data may be used for retrospective analysis in research or quality assurance. The system of nomenclature described here has been effectively used in one system and was easily adaptable to a second, unrelated medical record system. This nomenclature which is somewhat different from that used routinely by providers, was found to be acceptable by the users, although certain modifications were recommended.
展开▼
