, Volume 7, Issue 2, pp 103-109

A chartless record—Is it adequate?

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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.

This paper was presented at the Sixth Annual Symposium on Computer Applications in Medical Care, held in Washington, D.C., October 30–November 2, 1982, and is republished here with the permission of SCAMC and IEEE. © 1982 IEEE.