A clerking tool for the patient record system

1. BACKGROUND. The goal of the PEN&PAD (Elderly Care) project is to develop a patient record system to assist the many different professionals that care for patients in a hospital setting. At the core of the project is the use of structured data which can be reused in a variety of ways--both within the system for further manipulation and display, and externally for auditing and statistical purposes. To accommodate these needs, a compositional method of data entry called Structured Data Entry (SDE) was used in this application. SDE was developed in an earlier project PEN&PAD (GP)(1). Our application utilizes a network representation of the medical semantics that can be queried to obtain what is sensible to "say" about a particular concept. This functionality is contained within a separate application known as the Terminology Server (TeS), which has been developed within the GALEN project (2). The client application (the patient record system) requests information from the TeS which can then be used to produce compositional data entry forms that require the user to choose values for given attributes (e.g., if information pertaining to chest pain were being recorded, the attribute 'location' and a choice of possible values i.e., 'left' 'right' and 'bilateral' might appear on the form). Given the importance of capturing clinical information in a highly structured format, SDE is a valuable tool. However, its long term success depends on a very comprehensive model of the medical terminology corpus. This component is currently being studied by the GALEN team. 2. CURRENT WORK. We are developing a clerking tool to be used to create records for the newly admitted patient. The clinician seeks to identify a patient's problems based on physical examination and information obtained through conversation with the patient. Patients are usually admitted with a presenting complaint and obtaining more information about this complaint is an important part of the clerking process. While the physician may be able to use the clerking data to consider possible diagnoses right away, he/she often needs to review relevant body systems before a diagnosis is made. In traditional paper based clerking systems, notes are highly formalized but still subject to variation between clinicians. A typical clerking records information such as: 1) history of the presenting complaint; 2) previous medical history; 3) review of body systems; 4) medication; 5) social history; and 6) investigations. We have attempted to retain this clerking outline as much as possible, focusing primarily on the presenting complaint and review of body systems sections. To begin the clerking process, the user chooses a presenting complaint (from the list provided) to launch the 'clerking' window. Access buttons for the different clerking sections are positioned above a data entry window. This window contains a form for collecting information on the presenting complaint. The form is divided into sections to allow the user to record the absence or presence of an associated symptoms and other details. Free text comments can be added to the window, and a data display area shows information entered so far. The user can query the body system database by choosing a system from a menu. At this point the presenting complaint window is replaced by one on the body system in question. The user is free to switch back and forth between the presenting complaint and body system screens. On returning to a previously visited window, the user may pick up where he/she left off when exiting the window. Once the clerking is completed, the information is entered as a unit into the patient record with the date and clinicians name attached. Thereafter, the file becomes read-only. We are currently putting a prototype clerking system through field trials with clinicians from of a local hospital. In our demonstration, we hope to elaborate on these trials and their outcomes.