The concept of "template" assisted electronic medical record

A new design for an electronic medical record with flexible template generation was developed. The "template" in this paper refers to one of the tools that calls a user's attention to entering the data items for each problem or to ordering tests when they are due. The template shows the patient's previous data and guides physicians to record the consistent description. Two kinds of medical data dictionaries are prepared. Data representations of signs, symptoms, laboratory tests, and other examinations are defined in the check items dictionary. The problem dictionary contains the possible patient problems with relation to check items and other kinds of related subjects. This system provides Problem Oriented Medical Record (POMR) and the graphical presentation of various patient data. The system was designed to establish a constant and integrated medical record.