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Describes the application of the Problem-Oriented Medical Synopsis approach to medical records in a hospital medical ward and patient care. Principles of the problem-oriented medical synopsis; Procedure on patient's admission and discharge; Mechanism used during assessment of patient in hospital.

The introduction of formalized systems for data acquisition provide a basis for the investigation of medical decision making. Patients admitted to a general medical ward completed a comprehensive, medical history. Decisions relating to their subsequent diagnosis, investigation and management were made after complete investigation and were recorded with their questionnaire responses. A computer programme was developed to compare questionnaire responses from patients who did, and patients who did not have each particular decision made, and to assign a value to each question depending on the significance of its association with the decision. The set of values, one for each question, was termed a decision profile and was characteristic of that decision.