Non-categorical problem lists in a primary-care information system.
An ambulatory-care patient-tracking system has been implemented that records non-categorical problem descriptions in the outpatient problem list. The system does not restrict physicians to the use of predefined diagnostic categories. Instead, the system stores patient problems in a database as free-text records. Subsequent diagnostic categorization and coding is accomplished through prompted free-text input and appropriate reference databases. This system design allows an outpatient problem-list summary to reflect non-categorical health-status information in addition to coded medical diagnoses.
Wilton
R
R
Department of Pediatrics, UCLA School of Medicine.
D000555:Ambulatory Care Information Systems; D016208:Databases, Factual; D006751:Hospital Information Systems; D006785:Hospitals, University; D015141:Los Angeles; D016347:Medical Records Systems, Computerized; D008501:Medical Records, Problem-Oriented; D012984:Software