Prototype for future computer medical records.

Abstract A record file structure applicable to all forms of medical data is needed for a successful Medical Information System. A strategy for a direct-access generalized computer medical record, structured to store all essential medical data, is described. This record, which has been in use over two years, has a tree structure and is partitioned into patient visits, which are subdivided into medical meaningful parts. Standardization of variable (item) definitions, an item catalog, and sample patient record pages are demonstrated.

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