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The physical examination as it is usually recorded in the medical chart is incomplete, nonstandardized, and difficult to read. Retrieval of the information for patient care and clinical research is difficult and often impossible.
Physical examination check-off sheets have been widely employed, but these generally screen for abnormal findings which, when present, are described in the traditionally incomplete, nonstandardized, and (when hand recorded) illegible manner. Dictation of physical findings eliminates only the problem of legibility and introduces a new source of error—the clerical.
There is a need for improved methods of recording the findings of physical examinations to permit the adequate utilization of these data in both patient management and clinical research. Electronic data processing methods for storage and retrieval of physical examination data have been employed, but generally with the hospital chart as the data source and the punch card as the storage and computer input medium. Because of
Slack WV, Peckham BM, Van Cura LJ, Carr WF. A Computer-Based Physical Examination System. JAMA. 1967;200(3):224–228. doi:10.1001/jama.1967.03120160090013
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