Clinician-entered computerized psychiatric triage records.
Computer systems have become more accessible to clinicians as a result of the introduction of user-friendly software and low-cost terminals and printers. At a Veterans Administration medical center in California, an automated psychiatric record system is being developed that permits direct data entry by clinicians. The process began on the triage service, where psychiatrists are using a computerized form to enter clinical data into the patient's record during the triage interview. The author describes the computerized form, the factors influencing user acceptance, and the problems and benefits of direct data entry by clinicians. He believes that linkage of the computerized clinical data bases being developed at various institutions offers rich research possibilities, but only if the data elements included in the records can be standardized.
D002140:California; D006751:Hospital Information Systems; D006801:Humans; D008487:Medical History Taking; D008499:Medical Records; D011567:Psychiatric Department, Hospital / Q000458:organization & administration*; D012017:Referral and Consultation; D012984:Software