Computerised updating of clinical summaries: new opportunities for clinical practice and research?

Abstract

A new type of clinical summary, produced by copying standard descriptions of diseases on to a computer screen and editing them to match a patient's findings and diagnoses, was updated and reprinted as the patient's condition changed in the ward or as an outpatient. When this method was used to produce typed medical discharge summaries over a three month period, 73 out of 91 (80%) were sent out within a week after discharge compared with five out of 56 (9%) conventionally typed summaries received in a single general practice. Even completely new computerised summaries are quicker for the secretary to produce than conventional summaries, and the computerised summaries are designed to be scanned rapidly for relevant information. They can also be used to collect data automatically for research, clinical audit, and resource management.