The Alcohol Treatment Unit Computerized Medical Record (ATU CMR): A Clinician-Entered Inpatient Record

Described is an Alcohol Treatment Unit Computerized Medical Record (ATU CMR) system developed at the Jerry L. Pettis Memorial Veterans' Hospital in Loma Linda, CA. The system is used by multiple providers for the administrative and clinical management of patients admitted to an inpatient Alcohol Treatment Unit. This clinician-entered computer-generated medical record system replaces the handwritten record, from patient intake to discharge. Multiple choice options allow for the standardization of language while free text capabilities provide expression of more detailed patient information; data output is formatted into natural English sentences. Savings of costly personnel time, increased communication between multiple care providers, improved patient care, and creation of a research database in ASCII format are among the benefits experienced by using this system. The ATU CMR is now an indispensable part of the Alcohol Treatment Unit.