Journal of Medical Systems

, Volume 7, Issue 2, pp 103–109

A chartless record—Is it adequate?

Authors

  • W. W. Stead
    • From the Duke University Medical Center
  • W. E. Hammond
    • From the Duke University Medical Center
  • M. J. Straube
    • From the Duke University Medical Center
Articles

DOI: 10.1007/BF00995117

Cite this article as:
Stead, W.W., Hammond, W.E. & Straube, M.J. J Med Syst (1983) 7: 103. doi:10.1007/BF00995117

Abstract

The computerized medical record supported by The Medical Record (TMR) has been the only record of physician-patient encounters on the nephrology service of the Durham Veterans Administration Medical Center since April 1981. Physicians using the system evaluated the adequacy of the computerized record as a replacement for the paper chart. The computerized record was able to capture and display all pertinent data. Manual or computerized narratives provided a useful supplement to the core computerized record only in those rare instances that a physician needed to point out which of the data in the record were important to his decision making.

Copyright information

© Plenum Publishing Corporation 1983