A computerised out-patient medical records programme based on the Summary Time-Oriented Record (STOR) System.

Area of Science:

• Medical Informatics
• Health Information Technology
• Clinical Documentation

Background:

• Microcomputer advancements enable practical computerized outpatient medical records.
• Existing paper-based systems present challenges in data retrieval and analysis.
• The need for integrated systems for clinical decision support and research is growing.

Purpose of the Study:

• To develop and present a novel computerized medical record system.
• To complement existing paper-based medical record keeping.
• To explore the benefits for clinical decision-making, research, and medico-legal aspects.

Main Methods:

• Development of a program based on the Summary Time-Oriented Record (STOR) system.
• Implementation of a dual-window display for the Problem Oriented Medical Record (POMR) system.
• Utilizing context-sensitive child windows for detailed management plans and clinical notes.

Main Results:

• The system displays Subjective, Objective, Assessments, and Plans (SOAP) elements in the Reason For Encounter (RFE) window.
• The Problem List (PL) window presents the problem list with outcomes.
• Detailed management plans and clinical notes are accessible via child windows.

Conclusions:

• The STOR system offers a practical solution for computerized outpatient medical records.
• This innovation can enhance clinical decision-making and practice-based research.
• The system has significant medico-legal implications for healthcare providers.