Zimmerman J
Med Inform (Lond). 1978 Mar;3(1):27-35. doi: 10.3109/14639237809016060.
A study is reported of the ways in which 26 physicians, mostly internists, use the medical record. It was found that the items of greatest importance to the physicians, from the viewpoints of frequency of usage and of occasional interruption of the physician-patient transaction by being absent, were lab-test results, X-ray data, patient history, and previous treatments. The most common general problems cited uith the medical record were incompleteness (named by 38 per cent of the physicians), illegibility (27 per cent), and poor organization of the record (19 per cent).
一项关于26名医生（大多数是内科医生）使用病历方式的研究报告。研究发现，从使用频率以及因信息缺失偶尔打断医患交流的角度来看，对医生最重要的项目是实验室检查结果、X光数据、患者病史和既往治疗情况。被提及的病历最常见的一般问题是不完整（38%的医生提到）、字迹模糊（27%）以及记录组织不善（19%）。
