Development of Psychiatric Computerized Medical Records System.
- Author:
Chang Yoon KIM
1
;
Bum Seok JEONG
;
Chul LEE
;
Oh Soo HAN
Author Information
1. Department of Psychiatry, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea.
- Publication Type:Original Article
- Keywords:
Electronic medical records;
Computer-based patient record;
Psychiatry;
Medical informatics;
Problem oriented medical record
- MeSH:
Appointments and Schedules;
Cardiopulmonary Resuscitation;
Consensus;
Documentation;
Electronic Health Records;
Humans;
Information Systems;
Medical Informatics;
Medical Records;
Medical Records Systems, Computerized*;
Postal Service;
Research Personnel;
Weights and Measures
- From:Journal of Korean Neuropsychiatric Association
2002;41(1):168-183
- CountryRepublic of Korea
- Language:Korean
-
Abstract:
OBJECTIVES: Computer-based patient record (CPR, Electronic medical record) improves the quality of medical record which reflects the quality of clinical practice. It provides more efficient and convenient way of input, retrieval, storage, communication and management of medical data. The purpose of this study was to develop a practical domestic model and theoretical basis for CPR for psychiatric patients. This model can be applied in other clinical departments. METHODS: The contents and types of items to be included in the data-base were determined through consensus meetings of investigators on the basis of our previous works on the 'comprehensive assessment of symptoms and history in psychiatric disorders' and analysis of structure and items of medical records. The computer program(Asan Medical Center Psychiatric Information System, APIS, version 1.0) was developed using Oracle 7-3-4, Power builder 4.0, Hangul Windows NT and TCP/IP as a programming, development tools, system operation and transmission protocol. RESULTS: The characteristics of APIS are as follows. 1) APIS ensures comprehensive and high quality psychiatric record through combinations of free-text and structured data format and through many available 'help pop-up windows' of required items for better documentations. 2) APIS provides convenient and efficient ways of data input, particularly for narrative input of texts, with various tools such as 'template copy', various 'pop-up lists for block or phrase copy'. 3) APIS enables users to create and modify the template files or scales for research. 4) APIS which adopted principles of POMR (Problem Oriented Medical Record) makes cumbersome management of problem titles very convenient 5) APIS also provides additional statistics necessary for hospital audit and managements as well as mail communication and schedule management of department. 6) Access to APIS requires authorized ID and password where several levels of privileges (view only, edit allowed, master) are assigned to secure the data. And also modification of data was not allowed after completion of medical record except by persons with master ID. User's password and the data before modification can be traced. CONCLUSIONS: Our study results demonstrate the practical model and theoretical basis for CPR for psychiatric patients. We believe that this model and methods contained in this program can also be applied for developments of CPR for other clinical departments.
