Design elements for a computerized patient record
Related Experiment Video
Updated: Oct 18, 2026

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients
Published on: April 13, 2021
K Adelhard1, D Hölzel, K Uberla
1Institute of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University Munich, Germany. ade@ibe.med.uni-muenchen.de
Abstract:
Computerized medical record systems have to present user- and problem-oriented views of a patient record to health-care professionals. Presentation and manipulation of data must be easily adaptable to current and future demands of medical specialties and specific settings. During the definition, development and evaluation of a prototype of a computerized patient record system, design elements were elaborated to support physicians and other health-care professionals. Our approach shows a high degree of flexibility and adaptability to specific needs, problem orientation and connectivity to other systems, via a hospital information network. The explicit description of the contents of a patient record allows to augment the number of items that can be recorded without modifying the data structure. New views on patient data can be added to the system without interfering with the routine use of the system. Application in several medical specialties proved the feasibility of our prototype.
Related Concept Videos
Guidelines and Strategies for Safe Computer Charting
Maintain Confidentiality and Security:
Methods of Documentation VII: EMR
Legal Guidelines for Documentation
Formats for Nursing Documentation
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...
Data Reporting and Recording
Documentation of Nursing Diagnosis
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
