PubMed · 1997 · 30 citations · 0 references
ComputingHealth InformaticsHealth Services AdministrationClinical Information SystemsHealth Information SystemsPrimary CareClinical DocumentationElectronic Data Capture SystemsElectronic Health Record Documentation WorkflowsElectronic Health Records ManagementHealth RecordsHospital Information SystemsComputerized Clinical DocumentationElectronic Health Record DocumentationElectronic Health Record UseElectronic Health Records DocumentationElectronic Medical RecordsLaboratory Order EntryPatient Record ManagementStructured Problem Lists
Kaiser Permanente, Northwest Region, has implemented a comprehensive outpatient computer-based patient record. Clinicians use this system to document encounters, code diagnoses and procedures, maintain problem lists, order laboratory and radiology tests, and send prescriptions electronically. Clinicians also use it to send patient-specific messages and referrals between medical providers. More than 300 primary care clinicians in 10 separate clinics are now using the system in the delivery of care. This article describes our strategy and experience in the implementation of a comprehensive computer-based patient record.