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ASSOCIATION OF DATA ENTRIES WITH PATIENT RECORDS, CUSTOMIZED HOSPITAL DISCHARGE INSTRUCTIONS, AND CHARTING BY EXCEPTION FOR A COMPUTERIZED MEDICAL RECORD SYSTEM
ASSOCIATION OF DATA ENTRIES WITH PATIENT RECORDS, CUSTOMIZED HOSPITAL DISCHARGE INSTRUCTIONS, AND CHARTING BY EXCEPTION FOR A COMPUTERIZED MEDICAL RECORD SYSTEM
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机译：数据条目与患者记录，自定义医院出院说明以及计算机医学记录系统除外的收费
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摘要
Apparatus and a method for associating an electronic patient record with thecorresponding patient are described. A data processor accesses a patientrecord not associated with a unique person and compares the patientidentification data to corresponding data in a known patient record toidentify a set of likely matching patients. An input is provided for selectinga matching patient. Also disclosed is apparatus for providing customizedpatient discharge instructions relating information in the electronic patientrecord to patient-specific discharge instructions. A data processor insertsthe patient specific instructions into draft instructions, thereby producingpatient-specific discharge instructions. An updated version of charting byexception is disclosed, using macros to positively record data on a medicalrecord that is not specifically marked on a template by the attending medicalprofessional. Also described is an apparatus for translating a visualdocumentation language, communicating specific medical concepts in a highlycompact form, to clinically relevant English, enhancing the usability of apen/digital camera combination for data entry.
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