| Abstrakt: |
Medical documentation and transmission are impaired because of failures in the selection and tabulation of significant data at the source. Excessive narrative and lack of preciseness and specificity in the presentations pose serious difficulties in reference and interpretation. Suggestions for improvement evolved during the development of computer-oriented Current Medical Information and Terminology (CMIT). The Medical Record Form (MRF) is patterned after CMIT "worksheets" as used in the preparation of abstracts of textbooks and specialty journals. CMIT methodology is adaptable for MRF purposes, ie, in developing effective summaries of basic medical records to complement the original record, and to serve as input for computerization such as storage, indexing, retrieval, matching, "differential diagnosis," and possible applications in data base development. |
