American Hospital Association (2002) International Classification of Diseases, Ninth Revision, Clinical Modification (ICD–9–CM) (revised annually). Chicago, IL: AHA.
Clinical Systems Group (1998) Improving Clinical Communications. London: NHS Executive.
Cote, R. A., Rothwell, R. S., Palotay, J. L.
et al (1993) The Systematized Nomenclature of Human and Veterinary Medicine – SNOMED International. Northfield, IL: College of American Pathologists.
De Moor, G. J. E., McDonald, C. J. & Nothoven van Goor, J. (1991) Progress in Standardisation in Health Care Informatics. Amsterdam: IOS Press.
Department of Health (1998) Information for Health. London: HMSO.
Donnelly, W. J., Hines, E. & Brauner, D. J. (1992) Why SOAP is bad for the medical record. Archives of International Medicine, 152, 481–484.
Fienstein, A. R. (1988) ICD, POR and DRG: unsolved scientific problems in the nosology of clinical medicine. Archives of International Medicine, 148, 2269–2274.
Johnston, M. E., Langton, K. B., Haynes, R. B.
et al (1994) The effects of computer based clinical decision support systems on clinician performance and patient outcomes. A critical appraisal of research. Annals of Internal Medicine, 120, 135–142.
NHS Executive (1999) Learning to Manage Health Information. London: NHS Executive.
NHS Information Authority (2000) Towards an Information Standard for Organising Clinical Communications. London: NHS Information Authority.
O'Neil, M., Payne, C. & Read, J. (1995) Read Codes Version 3: A user-led terminology. Methods of Information in Medicine, 34, 187–192.
Rothwell, D. J. (1995) SNOMED-based knowledge representation. Methods of Information in Medicine, 34, 209–213.
Tang, P. C., Fafchamps, D. & Shortliffe, E. H. (1994) Traditional hospital records as a source of clinical data in the outpatient setting. In Proceedings of the Symposium on Computer Applications in Medical Care, pp. 575–579. Bethesda, MD: American Medical Informatics Association.
Tange, H. (1996) How to approach the structuring of the medical record? Towards a model for flexible access to free text medical data. International Journal of Biomedical Computing, 42, 27–34.
Weed, L. L. (1968) Medical records that guide and teach. New England Journal of Medicine, 278, 593–599.
World Health Organization (1992) Tenth Revision of the International Classification of Diseases and Related Health Problems (ICD–10). Geneva: WHO.
Wyatt, J. (1994) Clinical data systems, part 1: data and medical records. Lancet, 344, 1543–1547.