Text-interpreter language for flexible generation of patient notes and instructions.

摘要

An interpreted computer language has been developed along with a windowed user interface and multi-printer-support formatter to allow preparation of documentation of patient visits, including progress notes, prescriptions, excuses for work/school, outpatient laboratory requisitions, and patient instructions. Input is by trackball or mouse with little or no keyboard skill required. For clinical problems with specific protocols, the clinician can be prompted with problem-specific items of history, exam, and lab data to be gathered and documented. The language implements a number of text-related commands as well as branching logic and arithmetic commands. In addition to generating text, it is simple to implement arithmetic calculations such as weight-specific drug dosages; multiple branching decision-support protocols for paramedical personnel (or physicians); and calculation of clinical scores (e.g., coma or trauma scores) while simultaneously documenting the status of each component of the score. ASCII text files produced by the interpreter are available for computerized quality audit. Interpreter instructions are contained in text files users can customize with any text editor.