Computer-based medical clerking

All admissions to hospital begin with medical clerking. Thus, it is an essential element of any electronic patient record system. This paper describes some initial experiments to develop a computer-based clerking tool with which doctors can record their clinical observations. The clerking tool uses a structured data entry technique which is based upon an underlying semantic network of clinical terminology. This enables data to be captured and stored in a semantically structured manner, facilitating its use in computer-based record systems and also for audit, management, and decision support purposes. The prototype tool is described, and the evaluation and preliminary results obtained are reported. Initial results indicate that structured data entry is feasible for hospital-based clerking.