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Related Experiment Videos

A clerking tool for the patient record system

D McDermott1, H Heathfield, J Kirby

  • 1Medical Informatics Group, Department of Computer Science, University of Manchester, UK.

Medinfo. MEDINFO
|January 1, 1995
PubMed
Summary

This study introduces a structured data entry system for elderly care patient records, enhancing data reusability and clinical information capture. The system aims to improve consistency and efficiency in hospital patient documentation.

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Area of Science:

  • Medical Informatics
  • Health Information Systems

Background:

  • The PEN&PAD (Elderly Care) project aims to create a patient record system for hospital professionals.
  • Structured Data Entry (SDE) is utilized for reusable data, supporting internal manipulation and external auditing.
  • The system integrates a Terminology Server (TeS) for medical semantics, enabling structured data entry forms.

Purpose of the Study:

  • To develop a clerking tool for creating structured patient records for newly admitted patients.
  • To improve the process of gathering patient information, focusing on presenting complaints and body systems review.
  • To retain the traditional clerking outline while enhancing data structure and consistency.

Main Methods:

  • A clerking tool was developed, allowing users to select presenting complaints to launch data entry forms.
  • The system facilitates querying a body system database and allows seamless switching between complaint and system screens.
  • Information is entered as a unit into the patient record, becoming read-only upon completion.

Main Results:

  • A prototype clerking system is currently undergoing field trials with hospital clinicians.
  • The system aims to capture clinical information in a highly structured format, overcoming variations in traditional methods.
  • Early outcomes from field trials are expected to be elaborated upon.

Conclusions:

  • Structured Data Entry (SDE) is a valuable tool for capturing clinical information.
  • The long-term success of SDE relies on a comprehensive medical terminology model, currently under study.
  • The developed clerking tool shows promise for improving patient record creation in hospital settings.

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