Building the Computer-Based Patient Record

Reference: Norman, J. Building the Computer-Based Patient Record. Knowledge Systems Laboratory, Medical Computer Science, March, 1995.

Abstract: Computerization of the patient record offers solutions to the problems of the paper-based record, and the opportunity to expand the patient record to perform important new functions. In order to produce complete, flexible, and practical computer-based patient records we must develop models of the medical record, models of medical information (including controlled vocabularies), protocols for data interchange, and user interfaces for presenting and acquiring information.

Full paper available as ps.

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