Publications

An Interactive System for Generating Hospital Progress Notes

05/18/1991

Huei-Ning Natasha Ma, Martha Evens
Illinois Institute of Technology
Chicago, Illinois 60616

David A. Trace, Frank Naeymi-Rad
University of the Health Sciences/Chicago Medical School
North Chicago, IL 60064

Abstract
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 tally 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 handing 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 precents 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.

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