Information provided by the medical record plays a key role in the delivery of quality patient care. However, the traditional paper chart may be inaccessible, disorganized, illegible and/or voluminous, making the search for clinically significant data time-consuming, laborious and incomplete. In an effort to enhance medical decision support and assessment resources by providing faster, more convenient access to the clinical histories of hospitalized patients, Rex Hospital is in the process of

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... veloping a Clinical History Subsystem. In its initial phase, the subsystem creates a long-term clinical history file by extracting prior Rex admissions information (discharge diagnoses, medical and surgical procedures, allergies, and infectious disease alerts) from existing short-term data base files. Qualified users may print this data on demand for selected patients. A detailed description of the Clinical History Subsystem and its perceived role in the evolution toward a totally automated medical record will be presented.