Computerized clinical histories: the development of an HIS subsystem in a community hospital

摘要

In an effort to enhance medical decision support and assessment resources by providing faster, more convenient access to the clinical histories of hospitalized patients, Rex Hospital is in the process of developing a clinical history subsystem. In its initial phase, the subsystem creates a long-term clinical history file by extracting prior Rex admissions information (discharge diagnoses, medical and surgical procedures, allergies, and infectious disease alerts) from existing short-term database files. Qualified users may print this data on demand. A detailed description of the clinical history subsystem and its perceived role in the evolution toward a totally automated medical record are presented.