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Intelligent medical record—Entry (IMR-E)

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Abstract

This paper describes an automated medical record designed to allow providers to enter patient data at the point of care. The system runs on PCs and Macintoshes and uses a graphical user interface and object-oriented programming to take advantage of current mouse and pen technologies. The provider acquires all relevant patient data by pointing and clicking at selections on input screens, many of which contain anatomical drawings to help the provider quickly and accurately describe patient findings. The system also generates a grammatically correct progress note using the problem-oriented structure. Furthermore, items identified in the assessment and plans portion of the program can be ported to expert systems for medical decision assistance or to billing systems. The system allows the provider to obtain the necessary information on a focused patient visit in less than 5 min or to enter a complete history and physical.

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Authors and Affiliations

  1. From the UHS/The Chicago Medical School, 60064, North Chicago, Illinois

    David Trace, Frank Naeymi-Rad, David Haines, J. J. Shanthi Robert, Fabio deSouza Almeida, Lowell Carmony & Martha Evans

  2. Christian Broadcasting Network, 10985, Norfolk, Virginia

    David Trace, Frank Naeymi-Rad, David Haines, J. J. Shanthi Robert, Fabio deSouza Almeida, Lowell Carmony & Martha Evans

  3. San Francisco General Hospital, 94110, San Francisco, California

    David Trace, Frank Naeymi-Rad, David Haines, J. J. Shanthi Robert, Fabio deSouza Almeida, Lowell Carmony & Martha Evans

  4. Lake Forest College, 60045, Lake Forest, Illinois

    David Trace, Frank Naeymi-Rad, David Haines, J. J. Shanthi Robert, Fabio deSouza Almeida, Lowell Carmony & Martha Evans

  5. Illinois Institute of Technology, 60616, Chicago, Illinois

    David Trace, Frank Naeymi-Rad, David Haines, J. J. Shanthi Robert, Fabio deSouza Almeida, Lowell Carmony & Martha Evans

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  1. David Trace
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  6. Lowell Carmony
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  7. Martha Evans
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Trace, D., Naeymi-Rad, F., Haines, D. et al. Intelligent medical record—Entry (IMR-E). J Med Syst 17, 139–151 (1993). https://doi.org/10.1007/BF00996938

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