A computer-based outpatient medical record for a teaching hospital. 1991

C Safran, and C Rury, and D M Rind, and W C Taylor
Department of Medicine, Beth Israel Hospital, Boston, MA.

We developed a computer-based outpatient medical record system to facilitate direct physician interaction with the clinical computing system at the Beth Israel Hospital in Boston. During the 2 years since the medical record system was installed, 20 staff physicians, 5 fellows, 64 residents, and 11 nurse practitioners have entered 15,121 active problems and 1996 inactive problems for 3524 patients, as well as 12,651 active medications and 1894 discontinued medications for 3430 patients. Another 20,321 items were entered on health-promotion and disease-prevention screening sheets, and with the help of automatic updating by the computer, an additional 21,897 entries on screening sheets were made for 8686 patients. Clinicians wrote 10.9 +/- 12.8 (mean +/- SD) words per problem when they were working at the computer, as compared with 4.3 +/- 2.5 words per problem when they were writing in the paper medical record. We conclude that physicians will readily enter data directly into a computing system when they are given appropriate tools, and that they consider the computer-based problem list to be a valuable improvement over its paper counterpart. Use of a computer-based medical record system has obvious benefits for data management and patient care.

UI MeSH Term Description Entries
D010044 Outpatient Clinics, Hospital Organized services in a hospital which provide medical care on an outpatient basis. Ambulatory Care Facilities, Hospital,Hospital Outpatient Clinics,Clinic, Hospital Outpatient,Clinics, Hospital Outpatient,Hospital Outpatient Clinic,Outpatient Clinic, Hospital
D001900 Boston City located in Massachusetts.
D006746 Hospital Bed Capacity, 500 and over The number of beds 500 or more which a hospital has been designed and constructed to contain. It may also refer to the number of beds set up and staffed for use. Hospital Bed Capacity 500 Over
D006784 Hospitals, Teaching Hospitals engaged in educational and research programs, as well as providing medical care to the patients. Hospital, Teaching,Teaching Hospital,Teaching Hospitals
D000555 Ambulatory Care Information Systems Information systems, usually computer-assisted, designed to store, manipulate, and retrieve information for planning, organizing, directing, and controlling administrative activities associated with the provision and utilization of ambulatory care services and facilities. Ambulatory Information Systems,Information Systems, Ambulatory Care,Ambulatory Information System,Information System, Ambulatory,Information Systems, Ambulatory
D001291 Attitude of Health Personnel Attitudes of personnel toward their patients, other professionals, toward the medical care system, etc. Staff Attitude,Attitude, Staff,Attitudes, Staff,Health Personnel Attitude,Health Personnel Attitudes,Staff Attitudes
D016347 Medical Records Systems, Computerized Computer-based systems for input, storage, display, retrieval, and printing of information contained in a patient's medical record. Automated Medical Records Systems,Computerized Medical Records Systems,Automated Medical Record System,Automated Medical Record Systems,Automated Medical Records System,Computerized Medical Record System,Computerized Medical Record Systems,Computerized Medical Records System,Computerized Patient Medical Records,Medical Record System, Automated,Medical Record System, Computerized,Medical Record Systems, Automated,Medical Record Systems, Computerized,Medical Records System, Automated,Medical Records System, Computerized,Medical Records Systems, Automated

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