A Computer-oriented Approach to the Comprehensive Organization of Information in Hand-compiled Medical Records

The problem of the comprehensive organization of the medical record is discussed in this paper. The basis of the organizational scheme is the integration of both fixed-text and free-text components with constraints imposed upon the original formatting of the free text. To support the diagnostic procedure a component of the record is a »diagnosis sheet«, which embodies a differential diagnosis approach and is discussed in detail.

Results of more than two years of practical experience in the general medicine department of a regional hospital in Italy are presented. A trend towards a standardization of the medical terminology used was noted. Physicians' acceptance of a more rational conception of the medical record was high and a considerable flexibility in the language employed was observed. Finally, it is important to note that this new approach to the organization of the medical record was conceived in such a way as to make it processable by a computer located within the department itself. The initial experiences with the computerization of the record are presented and discussed with a view to future implementations and implications for cooperative, multidisciplinary research in medicine and information science.

In dieser Arbeit wird das Problem der umfassenden Organisation der Krankengeschichte erörtert. Grundlage des organisatorischen Schemas ist die Integration von sowohl feststehendem Text als auch Klartext, wobei bei der Formulierimg des Klartextes Einschränkungen auferlegt werden. Ein Bestandteil der Krankengeschichte zur Unterstützung cles diagnostischen Vorgehens ist clas »Diagnoseblatt«, welches einen clifferentialdiagnostisclien Ansatz beinhaltet und ausführlich erörtert wird.

Die Ergebnisse einer mehr als zweijährigen praktischen Erfahrimg in der Abteilung für Allgemein-meclizm eines Gebiets-Krankenhauses in Italien werden vorgestellt. Dabei wurde eine Tendenz zur Standardisierung der benutzten medizinischen Terminologie festgestellt. Die Bereitschaft der Arzte, ein rationelleres Konzept cler Krankengeschichte anzunehmen, war groß, unci eine erhebliche Flexibilität in der verwendeten Fachsprache wurde beobachtet. Schließlich ist es wichtig festzustellen, daß der neue Ansatz zur Organisation cler Krankengeschichte so konzipiert wurde, daß clie Verarbeitimg durch einen Computer innerhalb cler Abteilung möglich ist. Die ersten Erfahrungen mit cler automatischen Erstellung cler Krankengeschichte werden dargestellt unci im Hinblick auf zukünftige Implementationen und Implikationen für eine kooperative und multiclisziplinäre Forschung in Medizin und Informatik erörtert.

Keywords

Medical Record - Information Processing - Free Text Analysis - Differential Diagnosis - Medical Training

Schlüssel-Wörter

Krankengeschichte - Informationsverarbeitung - Klartextanalyse - Differential-diagnose - medizinische Ausbildung

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