Skip to main content
Book cover

Family Medicine pp 1133–1157Cite as

Record and Code Systems

  • Chapter
  • 169 Accesses

Abstract

Recently a family practice resident returned from a twomonth rural preceptorship and his evaluation of the physician and his practice was as follows: “I had the opportunity to see a lot of patients, observe a plethora of pathology, and do a lot of family practice you don’t see in a city, but the way he ran his office and his medical record system was mayhem.” The resident was saying, in effect, “The practice was running the physician, rather than the physician running the practice.”

This is a preview of subscription content, log in via an institution.

Buying options

Chapter
USD   29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD   74.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever

Tax calculation will be finalised at checkout

Purchases are for personal use only

Learn about institutional subscriptions

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Barnett GO: Costar: Computer-Stored Ambulatory Record—A Progress Report. Massachusetts General Hospital

    Google Scholar 

  2. Bass MJ, Newell JP, Dickie GL: An information system for family practice, Part I: Defining the practice population. J Fam Prac 3 :517, 1976

    Google Scholar 

  3. Bass MJ, Newell JP, Dickie GL: An information system for family practice, Part II: The value of defining a practice population. J Fam Prac 3:525, 1976

    CAS  Google Scholar 

  4. Brandejs JF, Kasowski MA, Pace G: Information systerns, Part II: The medical record. CMA J 113:903, 1975

    CAS  Google Scholar 

  5. Brandejs JF, Kasowski MA, Doyle CE: Information systems, Part III: Methodology and long-term applications. CMA J 113 : 1006, 1975

    CAS  Google Scholar 

  6. Brandejs JF, Kasowski MA: Information systems, Part IV: Protection of health care confidentiality. CMA J 113:1101, 1975

    CAS  Google Scholar 

  7. Brandejs JF, Kasowski MA, Murray HO: Information systems, Part V: What the users think. CMA J 114: 68–76, 1976

    CAS  Google Scholar 

  8. Brandejs JF, Kasowski MA, Davis NWL: Information systems, Part VI: What the computer can do for the primary care physician. CMA J 114:170, 1976

    CAS  Google Scholar 

  9. Brandejs JF, Kasowski MA, Fortin LJ: Information systems, Part VII: Problem-oriented medical records for family practice. CMA J 114 : 371,174,384, 1976

    CAS  Google Scholar 

  10. Coburn HN, Baker PM: Health hazard appraisal—A possible tool in health protection and promotion, Can JPH 64:490, 1973

    Google Scholar 

  11. Cromwell L, Andritti M, Weibell FJ, Pfeiffer EA, Steele B, Labok J: Medical Instrumentation for Health Care. Englewood Cliffs, NJ, Prentice-Hall, 1976

    Google Scholar 

  12. The National Ambulatory Medical Care Survey: Symptom Classification, DHEW Publication No. (HRA) 74. Rockville, Md, U.S. Department of Health, Education, and Welfare, Public Health Service, Health Resources Administration, National Center for Health Statistics, May 1974

    Google Scholar 

  13. Dinsdale SM, Gent M, Kline G, Milner R: Problemoriented medical records: Their impact on staff communication, attitudes and decision making. Arch Phys Med Rehabil 56:269, 1975

    PubMed  CAS  Google Scholar 

  14. Driggs MF: Problem-directed and medical information systems (Selected papers and discussion from the fourth annual scientific meeting of the Society for Advanced Medical Systems (SASM) held in Saddle Brook, New Jersey). New York, Intercontinental Medical Book Corporation, 1973

    Google Scholar 

  15. Fries JF: Alternatives in medical record formats. Med Care 12:876, 1974

    Article  Google Scholar 

  16. Giebink GA, Hurst LL: Computer Projects in Health Care. Ann Arbor, Michigan, Health Administration Press, 1975

    Google Scholar 

  17. Grace NT, Neal EM, Wellock CE, Pile DD: The family-oriented medical record. J Fam Prac 4:19, 1977

    Google Scholar 

  18. Jackson CB Jr, Drueger DE, Densen PM: Ambulatory care medical records: Uniform minimum basic data set. JAMA 234:1245, 1975

    Article  PubMed  Google Scholar 

  19. Ladou J, Sherwood JM, Hughes L: Health hazard appraisal in patient counseling (Preventive Medicine). West J Med 122:177, 1975

    PubMed  CAS  Google Scholar 

  20. Ludwig H: Computer Applications and Techniques in Clinical Medicine. New York, John Wiley, 1974

    Google Scholar 

  21. Luff CA, Walker PC: A computer code for the recording of patients’ problem. Computers and Biomedical Research 8:267, 1975

    Article  PubMed  CAS  Google Scholar 

  22. Manning PR: The problem-oriented record as a tool in management. Clin Obstet Gynecol 18:175, 1975

    Article  PubMed  CAS  Google Scholar 

  23. McCulloch W: Prospective medicine—improving the patient’s survival odds. Am Med News, September 2, 1974, p 21

    Google Scholar 

  24. McDonald CJ: Use of a computer to detect and respond to clinical events: Its effect on clinician behavior. Intern Med 84 :162, 1976

    Article  CAS  Google Scholar 

  25. Mesel E, Wirtschafter DD: On-line Medicaid Billing System for Physicians’ Services 8:479, 1975

    CAS  Google Scholar 

  26. Mesel E, Wirtschafter DD: Automation of a patient medical profile from insurance claims data: A possible first step in automating ambulatory medical records on at national scale. MMFQ, Health Soc, Winter 1976, p 29

    Google Scholar 

  27. Mesel E, Wirtschafter DD: Editorial: Automating ambulatory medical records: A claims-based medical profile. Comput Biomed Res 9:89, 1976

    Article  PubMed  CAS  Google Scholar 

  28. Morrison CC: The computer in family practice. J Maine Med Assoc, October 1973, p 56

    Google Scholar 

  29. Morrison CC: Pioneering with computers in family medicine. Patient Care, March 1, 1974, p 71

    Google Scholar 

  30. Newell JP, Dickie GL, Bass MJ: An information system for family practice, Part 3: Gathering encounter data. J Fam Prac 3:633, 1976

    CAS  Google Scholar 

  31. Payne RF: The computer as a tool in clinical medicine. South Med J 64:1216, 1971

    Article  PubMed  CAS  Google Scholar 

  32. Paymond S: Criteria in the choice of a computer systern, Part II: The computer in practice. JAMA 228: 1015, 1974

    Article  Google Scholar 

  33. Rakel RE: The problem-oriented medical record (POMR). AFP 10:100, 1972

    Google Scholar 

  34. Renner JH, Bauman EA: Problem-specific coding systems. J Fam Prac 2:279, 1975

    CAS  Google Scholar 

  35. Robbins LC, Hall JH: How to Practice Prospective Medicine. Indianapolis, Ind, Methodist Hospital of Indiana, 1970

    Google Scholar 

  36. Schmidt EC, Schall DW, Morrison CC: Computerized problem-oriented medical record for ambulatory practice. Med Care 12:316, 1974

    Article  PubMed  CAS  Google Scholar 

  37. Schneeweiss R, Stuart HW, Froom J, Wood M, Tindall H, Williamson JD: A conversion code from the RCGP to the ICHPPC classification system. J Fam Prac 5:415, 1977

    CAS  Google Scholar 

  38. Schneider D, Appleton L: A reason for visit classification system for ambulatory care. Med Rec News, October 1976, p 59

    Google Scholar 

  39. Tharp R: Records that let me see 50 percent more patients. Med Econ, February 23, 1976, p 72

    Google Scholar 

  40. The International Classification of Health Problems in Primary Care. Chicago, American Hospital Association, 1975

    Google Scholar 

  41. Thompson HC, Osborne CE: Office records in the evaluation of quality of care. Med Care 14:294, 1976

    Article  PubMed  CAS  Google Scholar 

  42. Walker HK: Commentary: The problem orientedmedical system. JAMA 236:2397, 1976

    Article  PubMed  CAS  Google Scholar 

Download references

Authors

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 1978 Springer Science+Business Media New York

About this chapter

Cite this chapter

Smith, H.T. (1978). Record and Code Systems. In: Taylor, R.B. (eds) Family Medicine. Springer, New York, NY. https://doi.org/10.1007/978-1-4757-3999-2_77

Download citation

  • DOI: https://doi.org/10.1007/978-1-4757-3999-2_77

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4757-4001-1

  • Online ISBN: 978-1-4757-3999-2

  • eBook Packages: Springer Book Archive

Publish with us

Policies and ethics