COMPUTER-BASED PATIENT RECORD - THE ESSENTIAL DATA SET APPROACH

The clamor for data to study the impact of care, to evaluate clinical performance and justify resource utilization is increasing. The data i n demand normally should exist in the record of a clinical encounter. Advances in information technology and software techniques have provid ed us with tools to develop and implement computer-based patient recor d systems. The issues that constrain development are integral issues o f clinical medicine, such as the variability in medical data, speciali zed practice of medicine, and differing demands of the numerous end-us ers of a medical record. This paper describes an approach to develop a computer-based patient record. The focus is on identification of the essential data set by infological data modeling and its implementation in a commercially available package for a physician's office.