Affiliations: [a] Department of Medical Informatics and Statistics, University of Limburg, Maastricht, Netherlands | [b] Department of Surgery, University of Nijmegen, Netherlands
Correspondence:
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Corresponding author: Dept. of Medical Informatics and Statistics, University of Limburg, PO Box 616, 6200 MD Maastricht, Netherlands. Tel.: 043-882240.
Note: [1] At the Second European Conference on Engineering and Medicine, held at Stuttgart during April 25–28 this contribution was orally presented as part of the Workshop on New Developments in Patient Oriented Medical Information Systems and Workstations organized by O. Wigertz, Linköping. The presentation was subsequently produced as a manuscript to be published in Technology and Health Care.
Abstract: Both a prototype medical record system and a protocol information system are presented. Both systems are used for research purposes. The philosophy behind the medical record system is that the system should provide both freedom of vocabulary and freedom of level of detail. The freedom of vocabulary is guaranteed by allowing free text entry. Freedom of level of detail is obtained by structuring the medical record in a hierarchical way and to allow the physician to enter data at the level of detail that suits him best. The protocol information system supports the physician in managing the patient. It guides the user through the protocol and allows him to obtain background information about the protocol. Both flowcharts and images are included. After each session a summary of the steps taken can be printed. A first evaluation indicates that physicians like to use the system and learn from it.
Keywords: Medical record system, Protocol, Information system, Structuring free text
