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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.
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