OPERATIONALIZING A BEDSIDE PEN ENTRY NOTEBOOK CLINICAL DATABASE SYSTEM IN CONSULTATION-LIAISON PSYCHIATRY

No current system of computerized data entry of clinical information i n consultation-liaison (C-L) psychiatry has been well received or has demonstrated that it saves the consultant's time. The inability to ach ieve accurate, complete, systematic collection of discrete variables a nd data entry in the harried C-L setting is a major impediment to the advancement of the subspecialty and health services research. The hand -held Notebook computer with Windows PEN ENTRY MICRO-CARES capabilitie s has permitted one-time direct entry of data at the time of collectio n at the patient's bedside. Variable choice and selection enhances the completeness and accuracy of data collection. For example, ICD-9, Axi s III diagnoses may be selected from a ''look-up'' which at the same r ime automatically assigns the appropriate code and diagnostic-related groups (DRG) number. A patient narrative can be typed at the nurse's s tation, a chart note printed for the medical record, and the MICRO-CAR ES literature database perused with the printing of selected citations , abstracts, and in some cases experts' commentaries for the consultee . The consultant's documentation time is halved using tile NOTEBOOK WI NDOWS PEN ENTRY MICRO-CARES software, with the advantage of move accur ate and complete data description than with the traditional handwritte n consultation records, Consultees preferred typewritten in contrast t o handwritten notes. The cost of the hardware (about $2000) is less th an that of an optical scanner, and it permits report generation and ar chival searches at the nurses' station without returning to the C-L of fice for scanning. Radio frequency or ethernet download from the Noteb ook permits direct data transfer to th C-L office archive computer.