A computer is used to improve the quality, consistency, and legibility of the patients' records in an ambulatory diabetes clinic of a large, teaching hospital. It has been programmed to produce printed records in a format familiar to the attending physician: the history and physical examination in a narrative style, and the laboratory data in a tabular display. When new data on a patient enter the system, a new report is generated automatically, superseding previous reports. Physicians enter data into the system by completing special forms which are a combination of check-lists and free narrative description. The results of the first six months of the routine operation of the system have encouraged its continued use and have stimulated the development of information searching programs, as well as automatic quality control reports.
Levy RP, Cammarn MR, Smith MJ. Computer Handling of Ambulatory Clinic Records. JAMA. 1964;190(12):1033–1037. doi:10.1001/jama.1964.03070250015003