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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
PubMed
Summary
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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.

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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.