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Computerization of the medical record in various outpatient settings has been successful but for anesthesiologists, the preoperative visit differs significantly. This study implemented a computerized version of a structured preanesthetic evaluation questionnaire that we had previously developed and which provided a starting point for developing a suitable vocabulary and workflow. Using the computerized version, pre-anesthetic evaluations were performed on 26 obstetric patients over a 20-week period. The introduction of a computer into the physician-patient relationship did not disrupt the examination. It markedly reduced time-consuming tasks (such as dictation), captured far more detail than found in our previously dictated and handwritten notes and provided immediately available data for quality assurance activities. [ABSTRACT FROM AUTHOR]

It is difficult to design and build computer systems to document medical care, especially if the entries are to be made by health care professionals. Not all software approaches are equally well suited to the task. Twenty-one specific software characteristics were identified that promote efficient development and support clinical needs. Using a software tool that satisfied these characteristics, we developed a computerized medical chart system that physicians can use to write notes and document patient encounters. The success of this system was due to a good fit between the basic capabilities of the software approach and the requirements of the project. These criteria can serve as the starting point for evaluating or developing other software applications that depend on physician input of clinical information.