MEDRIS: the hypermedia approach to medical record input-software engineering techniques for developing a hypermedia system

A medical record input system (MEDRIS) that makes use of hypermedia technology to provide a clinical tool for physicians to input patient data in a simple manner is described. The design of MEDRIS focuses on providing a natural working environment for the physicians. Physicians can easily learn to use MEDRIS since it eliminates the use of command-level entries and special function keys. MEDRIS comprises the following modules: history (chief complaints, review of systems, family history, etc), physical examination, laboratory, and medication. The chief complaint and the physical examination modules are discussed in detail. The software techniques adopted in building this system are explained. MEDRIS produces an immediate report of the data entered and an encounter file containing all the patient data collected during the current visit, which is added to the portable patient file