[The medical record at the center of medical informatics]

Several areas in medical institutions, particularly the technical and administrative ones have been governed by computers for a long time. The proper medical work field (diagnosis, treatment, follow-up, correspondence and billing) however has hitherto mostly been ignored by data processing. We describe an electronic medical record introduced 4 years ago. All aspects of medical practise and all the specialists involved in patient care are integrated in the electronic document. In the center is a medical base of knowledge adaptable to all specialties as well as an expert system for direct control of the data entered by all concerned persons.