Devices for structured data entry in electronic patient record.

Abstract

Electronic patient record is expected to have edit, data analysis, and decision supporting functions. To realize these functions, the entered data should be structured. We made a template based data entry system with some devices. We defined a template for each describing unit, i.e., symptom, physical finding and examination report. Template is composed of several describing elements (a pair of property and value), which form tree structure in general. When a template is selected, the top layers of the elements are displayed at once allowing data entry. When the data qualified by other elements is entered then system presents the second layer about this data at once. This enables users to skip entering some unnecessary items. Users can constitute a form by combining some templates frequently used in a situation. Furthermore, at the second patient visit, the system can present the templates used in the former patient visit to check the different point. These templates and forms can be made easily by editing the master data using template master maintenance program. The entered patient data are presented in progress note and flow sheet. In progress note, the entered data are translated into natural language. In the flow sheet, representative data of each template are present in the cell of the matrix whose line indicates the describing unit and column indicates date. If the cell is clicked, then the details are presented. Using this system, we made templates and forms for cardiovascular field and entered the data about an actual patient with angina pectoris. The time taken by inputting data is shorter than that by handwriting and the content is enough for a patient record. This system is practical for structured data entry in electrical patient record.