Biomedical subjects
Publications and source records attributed to D K Ulrich.
After briefly reviewing the evolution of clinical programs designed to handle the types of information needed for day-to-day decisions regarding patients, the authors discuss their SmartChart program, which is suited specifically to the maintenance of patient records in a private practice or a teaching hospital.
Microcomputers are perfectly suited for the input, storage, display, and printing of medical information. The most efficient method of data input and verification is by health professionals themselves, at the bedside or in the exam room. Battery-powered microcomputers are now available with all the power and function of desktops. One patient-care software package [Smart-Chart(tm)] allows entry of clinical data into battery-powered computers such as the Epson Geneva or Data General One, and two-way communication of such data with IBM-PC compatibles. This system inexpensively places a complete computer system in the hands of health professionals in all locations of practice (even at home for use during telephone calls). A dozen or so floppy disks can allow primary physicians to have immediate access to current information on all patients in their practice. Medical notation by computer may now achieve its full potential for clarifying medical records, improving patient care, and diminishing the frustration of medical practice.
A computerized notation system has been developed to produce a digital medical data base. Use of a separate physical record for every 1-4 patients allows several years of accumulated data to be easily accessible for patient "summaries" or admission "histories and physicals." To facilitate entry of data in the system, the physician is provided with a portable, complete computer system (HP-85, or Epson HX-20), a user-defined two-letter dictionary, and a program that produces all elements of the manual paper charting system. "Overview" and research data bases are developed from the digital medical data base records. In this paper, we report the efficiency of use of this computerized notation system in private outpatient and inpatient practice.
The Computerized Notation System (CNS) is a portable microprocessor system designed for use in outpatient clinics, hospital wards, and intensive care units. It can produce essentially all written communications required of both physicians and nurses, with printout at the bedside or in the clinic examining room. It is designed to ameliorate several problems which have limited direct computer entry by physicians and nurses (keyboard and processor access, marginal typing skills, lack of immediate printout, and logical restriction of menu choices). The system encourages and simplifies use of the problem-oriented approach to the patient, by producing organized, legible daily notes and patient summaries. Printouts of the system are compatible with the present hospital and clinic "paper charts." Clinical trials have confirmed the applicability, variability, and acceptability of the CNS in both hospital and outpatient practice.
A microprocessor-generated portable medical record has been developed as an alternative to a centralized digital medical data base. The medical information in this data base is processed and selected by physicians or nurses, with direct entry to the computer. Speed and accuracy of input are aided by this software program. Implementation of the program in several medical institutions has shown that the portable medical data base is useful in transfer of medical information among such institutions, and that the data base is adaptable to a variety of practice settings.
In 1988, the authors implemented a microcomputer charting system (SmartChart) within a busy dialysis unit and an outpatient dialysis practice, to be used as the primary recording instrument for physicians and nurses. The program defined the organization of the medical record as three types of titles: problems, therapies, and numerics. Each title had a variety of associated data, such as comments, dosages, values and normals. Predefined care plans were created, and keyboard entry was in a completely open format. Over the next two years, the overall format of this medical record proved to be highly effective, and strict problem orientation allowed both nurses and physicians to use the same problem list. A more specific organization of the title lists in the medical record was needed, however. Separate symbols were placed in front of: problem titles related to prior therapies; problems recorded during current therapies; History and Physical (H&P) data; Plans/Orders; and inactive problems. PRN therapies, those therapies related to patient treatments, vital signs, and numeric data recorded during treatments were identified. The basic format of the medical record that evolved has proven suitable for outpatient, inpatient, and specialized treatment centers.