Computer assisted generation of patient discharge letters using the cardiology information system greatly accelerates clinical reporting

After each discharge of a patient from our department a patient discharge letter needs to be generated to inform the patient´s general practitioner. Previously this was done after discharge by a resident using voice recorder dictation, aJier which rhe text was manually transcribed, corrected and sent to the addressees. The Cardiology information Sysrem (CARIS), developed in our department, contains all information pertaining to cathlab studies, pacemaker information, functional test results and images. We developed a dedicated module for CARIS that allows the semi-automatic generation of 70% of the discharge letter upon admission of the patient. At discharge the letter is completed and an electronic message is Sent to a supervisor, who must authorize the document. Upon authorization, the letter is automatically sent to a typist who prints out the letter for mailirlg purposes. This procedure decreased the time needed io generate the discharge letter from 12 weeks to 2 days.