The computer as an unbiased medical investigator. Experience on an active surgical service.

Abstract

An adaptable on-line computer system for entry, retrieval, and analysis of medical discharge summaries has been developed and applied in the Trauma Service of a busy city hospital. Each summary occupied 5 to 10 minutes of the physician's time and compared favorably in cost to the standard dictated summary. While the average dictated summary contained 15 +/- 7 relevant facts, the machine-generated summaries were found to have 53 +/- 20 relevant facts. The summaries are well organized, easily comprehensible, and a duplicate copy can be obtained at any time by using the patient's name or number for identification. To date, 495 discharge summaries have been entered and reside in the memory of the computer. Statistical analysis from the data base is done by the computer, thus eliminating human prejudice. It provides facility for rapid and accurate retrospective studies as well as pattern-of-care and individual case review.