An automated clinical record system must have the following characteristics: as far as the physician is concerned it must operate in natural language on standard sized paper; it must be able to accept information from the physician at a time when he is oriented to clinical terminology and a clinical mode of thinking; it must have an output which is clinically useful for the care and management of a patient; each item of information must be addressable so that it may act as an index for scientific information retrieval; it must be capable of accepting quantative and natural language information.Clinical information constitutes a mathematical set, only a few members of which are applicable to any particular clinical situation, and to which new members are constantly being added. The members of this set are seldom mutually exclusive. An acceptable system which is capable of processing this type of information has been designed utilizing the concepts of self-encoding forms and variable-field, variable-length records. Applications of these principles will expedite hospital automation, the establishment of drug evaluation information systems, and of regional and nationwide medical record systems.
