Optical Report Archiving of the Medicolegal Electronic Medical Record for an Enterprise Clinical Information System

摘要

Eliminating paper printouts from computerized Clinical Information Systems, while preserving an unalterable and contemporaneous electronic report of all clinical documentation, is a formidable task. Electronic shift reports must be accessible to physicians and other caregivers at all times, as a reference for direct patient care. These problems have been solved with a system that electronically stores all shift reports and other documentation from a CIS serving nine Intensive Care Units into an on-line optical jukebox. The optically archived reports preserve moment-by-moment patient status and caregiver documentation in a permanent, unalterable, medicolegal record. Access to these reports is integrated into an enterprise Web Viewing System which allows reports to be viewed and printed from any workstation on the hospital network.