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A chartless record--is it adequate?

作者信息

Stead W W, Hammond W E, Straube M J

出版信息

J Med Syst. 1983 Apr;7(2):103-9. 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.

摘要

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