Help–A Computer System for Medical Decision Making

The medical record is maintained for the express purpose of enabling the physician to deliver better care to the patient. But its usefulness in achieving that purpose has often been hampered by its inflation with voluminous, unorganized notes, and test results. The medical profession has begun to recognize this, and work has recently been done in reviewing the structure of the medical record with hopes of making improvements.1 Based on what has been learned so far, it appears that the most effective record is one containing a broad data base including many investigative procedures, while at the same time focusing the physician's attention on problems or diagnoses derived from the data base.2 These problems express only the essential information derived from the data base–that information which forms the basis for the treatment regimen.