A computer-based tool for generation of progress notes.

摘要

IVORY, a computer-based tool that uses clinical findings as the basic unit for composing progress notes, generates progress notes more efficiently than does a character-based word processor. IVORY's clinical findings are contained within a structured vocabulary that we developed to support generation of both prose progress notes and SNOMED III codes. Observational studies of physician participation in the development of IVORY's structured vocabulary have helped us to identify areas where changes are required before IVORY will be acceptable for routine clinical use.