Abstract
A electronic text-based medical record system used in a radiation oncology department since 1990 is described. The database is composed of a group of subfiles linked with a powerful relational database. The clinically relevant subfile structures are described and the hardware and software requirements for the system are itemized. Data entry is accomplished primarily by transcriptionists with some additional input by physicians at the time a dictation is reviewed. The database has been the exclusive source of radiation oncology notes since 1990. The flow of information from the dictaphone to the printed copy is described. Compared with a standard transcription service, addition clinical information is collected at the time of the patient encounter, and this information can be abstracted in reports. While not entirely replacing the paper record, the easy and rapid access to text-based digital information from any computer within the department has been invaluable.
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