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PubMed · 1807721

Non-categorical problem lists in a primary-care information system.

R Wilton
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Abstract

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.

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Ambulatory Care Information SystemsDatabases, FactualHospital Information SystemsHospitals, UniversityLos AngelesMedical Records Systems, ComputerizedMedical Records, Problem-OrientedSoftwareJournal Article

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R Wilton. 1991. Non-categorical problem lists in a primary-care information system.. https://pubmed.ncbi.nlm.nih.gov/1807721/

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