A computerised out-patient medical records programme based on the Summary Time-Oriented Record (STOR) System.
Advances in microcomputer hardware and software technology have made computerised outpatient medical records practical. We have developed a programme based on the Summary Time-Oriented Record (STOR) system which complements existing paper-based record keeping. The elements of the Problem Oriented Medical Record (POMR) System are displayed in two windows within one screen, namely, the SOAP (Subjective information, Objective information, Assessments and Plans) elements in the Reason For Encounter (RFE) window and the problem list with outcomes in the Problem List (PL) window. Context sensitive child windows display details of plans of management in the RFE window and clinical notes in the PL window. The benefits of such innovations to clinical decision making and practice based research and its medico-legal implications are discussed.
Cheong
P Y
PY
Cheong Medical Clinic, Singapore.
Goh
L G
LG
Ong
R
R
Wong
P K
PK
D006801:Humans; D016347:Medical Records Systems, Computerized; D008501:Medical Records, Problem-Oriented