Journal of Medical Systems

, Volume 7, Issue 2, pp 103–109

A chartless record—Is it adequate?

  • W. W. Stead
  • W. E. Hammond
  • M. J. Straube
Articles

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.

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References

  1. 1.
    Hammond, W. E., Stead, W. W., Straube, M. J., and Jelovsek, F. R., A clinical data base management system.Policy Inform. 4:79–86, 1980.Google Scholar
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    Hammond, W. E., Stead, W. W., Straube, M. J., and Jelovsek, F. R., Functional characteristics of a computerized medical record.Meth. Inform. Med. 19:157–162, 1980.Google Scholar
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    Garrett, L. E., Stead, W. W., and Hammond, W. E., Effect of automated records on provider proficiency.Clin. Res. 30:299a, 1982.Google Scholar
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    Stead, W. W., and Hammond, W. E., The impact of a computerized medical record on clinical decision making for nephrology patients.Proceedings of the Joint Conference of the Society for Computer Medicine and the Society for Advanced Medical Systems, 1981, pp. 29–30.Google Scholar

Copyright information

© Plenum Publishing Corporation 1983

Authors and Affiliations

  • W. W. Stead
    • 1
  • W. E. Hammond
    • 1
  • M. J. Straube
    • 1
  1. 1.From the Duke University Medical CenterDurham

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