Data Acquisition and the Computer-based Patient Record

  • Allan H. Levy
  • David P. Lawrance
Part of the Computers in Health Care book series (HI)


Consideration of data acquisition for the computer-based patient record (CPR) should be accompanied by general understanding of the scope, intended contents and function of the patient record. The medical record serves as an active component of the ongoing care process. It contains information on the origins, progress and outcome of a patient’s disease(s) so that optimal care can be provided for the patient over an extended period of time. It contains documentation from all relevant sources. Coupled with medical knowledge bases and appropriate programs for medical inference, the data in the patient record serves as a decision support aid and as a pointer to medical literature (McDonald and Tierney 1986).


Data Entry Free Text Nursing Unit Laboratory Information System Medical Knowledge Base 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. Fischer, P.J., W.C. Stratmann, H.P. Lundsgaarde, and D.J. Steele. 1980. User reaction to PROMIS: Issues related to acceptability of medical innovations. Proceedings of the Fourth Annual Symposium on Computer Applications in Medical Care, J. O’Neil, ed. Washington, D.C.: IEEE Computer Society Press.Google Scholar
  2. Humphreys, B., and D. Lindberg. 1989. Building the unified medical language system. Proceedings of the Thirteenth Annual Symposium on Computer Applications in Medical Care, L. Kingsland II, ed. Washington, D.C.: IEEE Computer Society Press.Google Scholar
  3. McDonald, C.J., S.L. Hui, D.M. Smith, W.M. Tierney, S.J. Cohen, M. Weinberger, and G.P. McCabe. 1984. Reminders to physicians from an introspective medical record: A two year randomized trial. Annals of Internal Medicine 199:330.Google Scholar
  4. McDonald, C.J., and W.M. Tierney. 1986. The medical gopher. A microcomputer system to help find, organize and decide about patient data. Western Journal of Medicine 145:823.PubMedGoogle Scholar
  5. Pryor, D., R.M. Gardner, P.D. Clayton, and R.H. Warner. 1983. The HELP system. Journal of Medical Systems 7:87–102.PubMedCrossRefGoogle Scholar
  6. Slack, W. 1984. A history of computerized medical interviews. MD Computing 5:52.Google Scholar
  7. Weed, L.L. 1969. Medical records, medical education and patient care: The problemoriented record as a basic tool. Chicago: Year Book Medical Publishers.Google Scholar

Copyright information

© Springer Science+Business Media New York 1992

Authors and Affiliations

  • Allan H. Levy
  • David P. Lawrance

There are no affiliations available

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