We can also greatly enhance and streamline the entry of running notes in the medical record. These notes are usually structured as a list of “items”, where each item corresponds to a type of data, or a clinical sign or symptom. The actual selection of which items to use depends on why we’re seeing the patient, as expressed through the “type of contact” (or “problem”). The content (value) of the items, however, is free text, but usually limited to a few variations only. These, the system can learn and present.
When you’re seeing a patient, it’s very often useful to do a search for diagnostic and therapeutic guidelines, medical articles, regional or institutional recommendations and so on. These searches need to be restricted to appropriate sources, not just the wild internet. Once you’ve done a search and found some useful information, you’d probably want to save a reference to it and be able to locate it again the next time you see this patient, or another patient with a similar problem.