In an attempt to provide data for medical audit, to standardise the information on discharge letters and to speed communication, a computerised discharge form was introduced for a catchment area of 20,000 people over 65 years. The programme, based on a surgical audit programme using DBASE II, was developed by one of us to run on an Amstrad PCW. This produced a discharge summary on a standard layout which gave the date of admission, the patient's name, date of birth and address as well as the consultant and GP's name. The patient's diagnosis (according to ICD-9), and a list of disciplines and facilities involved in follow-up preceded brief notes on history and progress. Date of discharge was followed by a list of medication and a space for ‘other information’. All this was contained on one side of A4 paper.
Email your librarian or administrator to recommend adding this journal to your organisation's collection.