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Title Computer Assisted Daily Progress Notes for Infants (Abstract)
Author(s) Ray Duncan and Jeffrey J. Pomerance
Source Pediatric Research, Vol. 14, No. 4
Publication Date April 1980
Abstract Hand-written daily progress notes are frequently illegible, incomplete, and appear in nonstandardized form, making summarization and data retrieval difficult or impossible. A system of programs has been developed to assist in the computer preparation and printing of problem-oriented progress notes in a neonatal intensive care setting. To write a progress note, one designates a patient from a census file, selects one of the patients problems from a standard problem list, and then proceeds to answer standardized questions pertinent to the problem selected. Most questions are molded into a yes/no or multiple choice format, although free text descriptions are always available. Upon completing one problem, other problems specific to the infant are selected in turn, including findings on physical examination. Upon completion of an infant's problem list, the progress note is printed for review and signature. Daily patient data is stored in the cumulative data file. A detailed example of the physician-computer interaction process will be presented. Currently, the problem list consists of 21 items. It is projected that the final list will cover >95% of neonatal problems. The system is flexible enough to permit regular modification to correct ambiguities and errors and to incorporate new information. Further programs are being developed to search the infant's cumulative data file and print weekly, monthly, and final reports.

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