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Computer-based medical clerking
H A Heathfield1, D McDermott, J Kirby
1Computing Department, Manchester Metropolitan University, Manchester, UK.
Medinfo. MEDINFO
|January 1, 1995
Summary
This study introduces a computer-based medical clerking tool for doctors to record clinical observations. Initial results show structured data entry is feasible for hospital admissions, improving electronic patient records.
Area of Science:
- Medical Informatics
- Clinical Documentation
Background:
- Medical clerking is a critical first step in hospital admissions.
- Integrating clerking into electronic patient record (EPR) systems is essential.
- Current methods may lack structured data capture for advanced use.
Purpose of the Study:
- To develop and evaluate a computer-based clerking tool.
- To explore structured data entry for clinical observations.
- To assess the feasibility of semantic data capture in hospital clerking.
Main Methods:
- Development of a prototype computer-based clerking tool.
- Utilized structured data entry based on a semantic network of clinical terminology.
- Conducted evaluation and reported preliminary results.
Main Results:
- Demonstrated the feasibility of structured data entry for hospital clerking.
- The tool captures data in a semantically structured manner.
- Facilitates use in EPRs, audit, management, and decision support.
Conclusions:
- Structured data entry is a viable approach for hospital medical clerking.
- The developed tool supports semantically rich data capture.
- Potential to enhance EPR systems and clinical data utilization.