The problem of the comprehensive organization of the medical record is discussed in this paper. The basis of the organizational scheme is the integration of both fixed-text and free-text components with constraints imposed upon the original formatting of the free text. To support the diagnostic procedure a component of the record is a »diagnosis sheet«, which embodies a differential diagnosis approach and is discussed in detail. Results of more than two years of practical experience in the general medicine department of a regional hospital in Italy are presented. A trend towards a standardization of the medical terminology used was noted. Physicians' acceptance of a more rational conception of the medical record was high and a considerable flexibility in the language employed was observed. Finally, it is important to note that this new approach to the organization of the medical record was conceived in such a way as to make it processable by a computer located within the department itself. The initial experiences with the computerization of the record are presented and discussed with a view to future implementations and implications for cooperative, multidisciplinary research in medicine and information science.
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Certttti et al. (1979) studied this question.