An interactive system for generating hospital progress notes

  • Huei-Ning Natasha Ma
  • Martha Evens
  • David A. Trace
  • Frank Naeymi-Rad
Track 12: Software Engineering
Part of the Lecture Notes in Computer Science book series (LNCS, volume 507)


Research has shown that physicians find a medical expert system much more attractive if the system can provide in addition to diagnostic support some relief from the heavy burden of responsibility for daily record keeping required in hospital practice. This paper introduces a sophisticated interactive system for generating daily progress notes designed to function as an integral part of MEDAS (the Medical Emergency Decision Assistance System). MEDAS is a pattern-recognition expert system, using multi-membership Bayesian inference. At hospital admission, the MEDAS diagnosis module and severity module produce a problem list and assign a severity code to each problem. In many hospitals, physicians are expected to provide daily progress notes discussing the patient's condition with respect to each problem area. For each problem, they need to consider subjective and objective information, assessment and make a plan for handling the problem. The items to be considered depend on the specific problem: remembering these items is a huge memory load; writing it all down is very time-consuming. Our system presents the physician with a series of problem-specific menus, making data entry easy and rapid. Finally, it automatically generates the necessary output for the patient record.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. [1]
    G.O. Barnett. The application of computer-based medical-record systems in ambulatory practice. N Engl J Med. 1984;310:1643–1650.CrossRefGoogle Scholar
  2. [2]
    M. Ben-Bassat, R.W. Carlson, V.K. Puri, M.D. Davenport, J.A. Schriver, M.H. Weil. Pattern-based interactive diagnosis of multiple disorders: The MEDAS system. IEEE Transactions in Pattern Analysis and Machine Intelligence. 1980;148–160.Google Scholar
  3. [3]
    M.B. Bischoff, E.H. Shortliffe, A.C. Scott, R.W. Carlson, C.D. Jacobs. Integration of a computer-based consultant into the clinical setting. Proceedings of the Seventh Annual Symposium on Computer Applications in Medical Care, IEEE, 1983:149–152.Google Scholar
  4. [4]
    A.R. Feinstein. The problems of the “problem-oriented medical record.” Annals of Internal Medicine. 1973;78:751–762.Google Scholar
  5. [5]
    W.J. Fessel, E.E. Van Brunt. Assessing quality of care from the medical record. N Engl J Med. 1972;286:34–38.Google Scholar
  6. [6]
    N.N. Finer, A.J. Fraser. Neonatal data base and automated discharge summary using a personal computer and proprietary software. Pediatrics. 1985;76:(2) 269–273.Google Scholar
  7. [7]
    R.H. Fletcher. Auditing problem-oriented records and traditional records: a controlled comparison of speed, accuracy, and identification or errors in medical care. N Engl J Med.. 1974;290:829–833.CrossRefGoogle Scholar
  8. [8]
    H.H. Friedman. Problem-Oriented Medical Diagnosis. Little Brown and Company, Boston, 1987.Google Scholar
  9. [9]
    W.E. Hammond, W.W. Stead, M.J. Straube, F.W. Jelovsek. Functional characteristics of a computerized medical record. Methods Inf Med. 1980; 19:157–162.Google Scholar
  10. [10]
    J.W. Hurst. Ten reasons why Lawrence Weed is right. N Engl J Med. 1971, 284:51–52.CrossRefGoogle Scholar
  11. [11]
    I.M. Kuhn, G.W. Wiederhold. The evolution of ambulatory medical systems in the U.S. In: H.G. Heffernan, (ed.) Proceedings of the Fifth Annual Symposium on Computer Applications in Medical Care. IEEE, 1981:80–85.Google Scholar
  12. [12]
    C.J. McDonald, S.L. Hui, D.M. Smith. Reminders to physicians from an introspective computer medical record. Annals of Internal Medicine. 1984. 100:130–138.Google Scholar
  13. [13]
    M.J. Meldman, D. Harris, J.P. Robert, E.A. Johnson. A computer-assisted, goal-oriented psychiatric progress note system. Am J Psychiatry. 1977;134:38–41.Google Scholar
  14. [14]
    F. Naeymi-Rad. A feature dictionary for a multi-domain medical knowledge base. Proceedings of the Twelfth Annual Symposium on Computer Applications in Medical Care, IEEE, 1988:212–217.Google Scholar
  15. [15]
    M.S. Roberts, J.D. Zibrak, A. Siders. The development of an on-line, partially automated discharge summary and core clinical data-base in an existing hospital information system. Proccedings of the Thirteenth Annual Symposium on Computer Applications in Medical Care. IEEE, 1989:649–653.Google Scholar
  16. [16]
    D.W. Simborg, Q.E. Whiting-O'Keefe. Summary time oriented record (STOR) — a progress report. Proceedings of the Fifth Annual Symposium on Computer Applications in Medical Care. IEEE, 1981:100–103.Google Scholar
  17. [17]
    R.P. Smith, G.B. Holzman. The application of a computer data base system to generation of hospital discharge summaries. Obstetrics and Gynecology. 1989;73:(5), 803–807.Google Scholar
  18. [18]
    W.W. Stead, W.E. Hammond, M.J. Straube. A chartless record — is it adequate? Proceedings of the Sixth Annual Symposium on Computer Applications in Medical Care. IEEE, 1982:89–94.Google Scholar
  19. [19]
    P.H. Stern, B.S. Rubin. Computerized discharge sumaries. Arch Phys Med Rehabil. 1979;60:25–29.Google Scholar
  20. [20]
    L.L. Weed. Medical Records, Medical Education, and Patient Care. The Problem-Oriented Record as a Basic Tool. Chicago, Year Book Medical Publishers, Inc., 1970.Google Scholar
  21. [21]
    Q.E. Whiting-O'Keefe, D.W. Simborg, W.V. Epstein, A.A. Warger. A computerized summary medical record system can provide more information than the standard medical record. JAMA. 1985;254:1185–1192.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 1991

Authors and Affiliations

  • Huei-Ning Natasha Ma
    • 1
  • Martha Evens
    • 1
  • David A. Trace
    • 2
  • Frank Naeymi-Rad
    • 2
  1. 1.Illinois Institute of TechnologyChicago
  2. 2.Chicago Medical SchoolUniversity of the Health SciencesNorth Chicago

Personalised recommendations