Regularization and Stylization of Medical Records

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Abstract
Medical documentation and transmission are impaired because of failures in the selection and tabulation of significant data at the source. Excessive narrative and lack of preciseness and specificity in the presentations pose serious difficulties in reference and interpretation. Suggestions for improvement evolved during the development of computer-orientedCurrent Medical Information and Terminology (CMIT).TheMedical Record Form (MRF)is patterned afterCMIT"worksheets" as used in the preparation of abstracts of textbooks and specialty journals. CMITmethodology is adaptable forMRFpurposes, ie, in developing effective summaries of basic medical records to complement the original record, and to serve as input for computerization such as storage, indexing, retrieval, matching, "differential diagnosis," and possible applications in data base development.

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