The Development of an On-Line Partially Automated Discharge Summary and Core Clinical Data-Base in an Existing Hospital Information System

摘要

We describe the development of a hospital-wide computer system that produces on-line, partially automated discharge summaries, assists nursing staff with discharge functions, and stores a core clinical database on all patients. The system was created using only tools and functions contained within the existing order-entry/results reporting hospital information system. Data enters the discharge database in three ways: direct transfer from the information system, on line selection by physicians and nurses of specific data already contained in the system (eg. lab and radiology results), and by typed input of varying amounts of text (eg. chief complaint, hospital course). If completed the night prior to discharge, the system produces several products for residents and nurses, included typed prescriptions, the printed discharge summary, nursing referral or patient care forms, and simple discharge planning information for the patient. During the course of a 9 week pilot program, 428 summaries were completed on the system, 420 of which met JCHAO criteria.