Direct Entry of Patient Data to a Portable, Briefcase Computer: Interface with Overview Medical Data Base at the Office

摘要

A “Computerized Notation System” is described, which allows capture of all the physician's or nurse's notes, using a 4 lb portable computer. The system produces all of the written communication required in daily practice, including daily notes, prescriptions, orders, “History and Physicals”, and “Discharge Summaries”. By “flagging” certain items, it is possible to transmit data from the portable computer to an office computer and “centralized” database. Programs now in development will allow this computer to generate Quality Assurance and research reports, and perform scheduling and billing operations.