A Computer Based Medical Record System

Abstract

This paper reports the design and implementation of a computer based medical record system. Clinical data from a 27-bed general medical ward are captured at the point of generation and entered into a computer through a remote terminal. The data stored at present for each patient-admission include the identification, diagnoses, clinical history, findings on physical examination and a problem oriented case synopsis. Commands are available to enter, validate, reformat, and finally store the data permanently on computer files. Other commands locate all or part of specified records, decode and reformat the data for output, and print the output at the remote terminal or on a high speed line printer. Commands are also available for data file maintenance and for statistical research on the stored records. The system has been in operation for two years and over 1,000 records are currently computer-stored.