A Computer Based Medical Record System^[*)]

This paper reports the design and implementation of a computer based medical record system. Clinical data from a 27-bed general medical ward are captured at the point of generation and entered into a computer through a remote terminal. The data stored at present for each patient-admission include the identification, diagnoses, clinical history, findings on physical examination and a problem oriented case synopsis. Commands are available to enter, validate, reformat, and finally store the data permanently on computer files. Other commands locate all or part of specified records, decode and reformat the data for output, and print the output at the remote terminal or on a high speed line printer. Commands are also available for data file maintenance and for statistical research on the stored records. The system has been in operation for two years and over 1,000 records are currently computer-stored.

Die Arbeit berichtet über Planung und Implementierung eines Systems zur Computer-unterstützten Krankenblattbearbeitung. Klinische Daten aus einer allgemein-internistischen Station mit 27 Betten werden im Zeitpunkt ihrer Entstehung erfaßt und über Terminal in den Computer eingegeben. Die zur Zeit für jede Patientenaufnahme gespeicherten Daten umfassen Identifikationsmerkmale, Diagnosen, Anamnese, Befunde der ärztlichen Untersuchung und eine problemorientierte Synopse des. Falles. Befehle für die Daten-Eingabe, -Prüfung, -Formatierung und schließliche dauernde Speicherung in Dateien sind verfügbar. Andere Befehle ermitteln spezifizierte Krankenblätter oder Teile daraus, entschlüsseln und formatieren die Daten für die Ausgabe und drucken über ein Terminal oder einen Schnelldrucker aus. Befehle zur Dateiführung und für die statistische Auswertung der gespeicherten Krankenblätter stehen ebenfalls zur Verfügung. Das System ist seit zwei Jahren in Betrieb; zur Zeit sind mehr als 1.000 Krankenblätter im Computer gespeichert.

Key-Words

Medical Record - Information System - Medical History - Physical Examination - Discharge Summary

Schlüssel-Wörter

Krankenblatt - Informationssystem - Anamnese - ärztliche Untersuchung - Entlassungsbericht

^*) Publication No. 1899 from The Walter and Eliza Hall Institute of Medical Research.

Publication History

Publication Date:
12 February 2018 (online)

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