The application of computers to medical records: a computer system for the storage and retrieval of medical records.

Abstract

SummaryThis paper describes a system for the storage and retrieval by computers of components of the medical record. This system has been in operation for 18 months and there are over 550 clinical records stored on magnetic tape, representing some 700 separate patient admissions. The system stores data of identification, diagnosis codes, the summary of the medical record, results of laboratory tests, consultants' opinions and details of treatment. Three programmes have been written to process this data. The first provides for any number of printouts of the record of a patient's most recent admission. The second, the “update” programme, merges new records into their correct sequence on the magnetic tape. The third, the “record retrieval” programme, allowed a patient's complete medical record to be printed out as needed from the information on magnetic tape.The present project has as the ultimate goal a computer‐based Patient Information Centre (PIC) which will receive, contain and transmit all relevant medical data concerning patients in hospital; the data in this information system could be available through computer consoles at any desired site within the hospital.