The authors describe a computer system that develops a structured
progress note for inclusion in the medical record. The progress note system
reflects a goal-oriented patient treatment process and also provides for
retrospective analysis of progress note information to accommodate research
and review objectives. The system, which has met with a high degree of
clinician acceptance, has resulted in improved case documentation, more
timely and comprehensive notes, a higher level of objectivity, and a
considerable reduction in the time required to organize and record progress
note data.Abstract Teaser