An on-line method for the acquisition of medical information for computer processing as applied to radiotherapy

Based on a structured medical record, specially designed for patients with malignant disease, an on-line data capture system has been developed. This enables the collection of virtually any type of information contained in the patient's case notes. The structure of the record is described, with actual examples. The record is typed on a typewriter terminal linked to a mini-computer. Data is recorded as code + heading + value string. The headings are identified automatically, and an internal code generated, describing the type of information. Record keeping according to the principles described was introduced in clinical routine at the department in 1971. Data collection was implemented later that year, using an off-line magnetic tape encoder (IBM MT72). The system has been developed further and converted to a versatile on-line system. The data base, collected with these systems, now contains data on about 20,000 patients.