Computer Processing of Medical Text Information**)

Abstract

The present form of the medical record evolved when patient care was primarily a single physiciansingle patient relationship. However, in recent decades, there have been radical changes in the needs and patterns of health care delivery, and this scrap-book format for a medical record is grossly deficient.The largest portion of the medical record consists of narrative or free text which is hand-written in relatively unstructured, and often illegible, prose. Although the computer can be used for medical record processing by the unmodified entry of data in prose form, there are very critical limitations in such applications. A more challenging approach is to collect the information in an interactive, conversational technique between the user and the computer, where there is a predetermined branching structure of the data and a fixed vocabulary. The information is entered by the user selecting the desired items from a list on a display screen. The presentation of the particular display by the computer is determined by all the previous choices made by the user. This style of collecting information not only insures clear and unambiguous data, but also facilitates continuing medical education, medical audit, and clinical investigation.