title: A prototype of a computerized patient record.
abstract: Computerized medical record systems (CPRS) should present user and problem oriented views of the patient file. Problem lists, clinical course, medication profiles and results of examinations have to be recorded in a computerized patient record. Patient review screens should give a synopsis of the patient data to inform whenever the patient record is opened. Several different types of data have to be stored in a patient record. Qualitative and quantitative measurements, narratives and images are such examples. Therefore, a CPR must also be able to handle these different data types. New methods and concepts appear frequently in medicine. Thus a CPRS must be flexible enough to cope with coming demands. We developed a prototype of a computer based patient record with a graphical user interface on a SUN workstation. The basis of the system are a dynamic data dictionary, an interpreter language and a large set of basic functions. This approach gives optimal flexibility to the system. A lot of different data types are already supported. Extensions are easily possible. There is also almost no limit concerning the number of medical concepts that can be handled by our prototype. Several applications were built on this platform. Some of them are presented to exemplify the patient and problem oriented handling of the CPR.
authors.affiliation: Department of Medical Informatics, Biometrics and Epidemiology, Ludwig-Maximilians-Universität, Munich, Germany.
authors.forename: K
authors.initials: K
authors.lastname: Adelhard
authors.forename: R
authors.initials: R
authors.lastname: Eckel
authors.forename: D
authors.initials: D
authors.lastname: Hölzel
authors.forename: W
authors.initials: W
authors.lastname: Tretter
mesh_terms: D006801:Humans; D016247:Information Storage and Retrieval; D016347:Medical Records Systems, Computerized; D014584:User-Computer Interface