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The pocket medical record--do we need a centralized medical data base?
Abstract:
A microprocessor-generated portable medical record has been developed as an alternative to a centralized digital medical data base. The medical information in this data base is processed and selected by physicians or nurses, with direct entry to the computer. Speed and accuracy of input are aided by this software program. Implementation of the program in several medical institutions has shown that the portable medical data base is useful in transfer of medical information among such institutions, and that the data base is adaptable to a variety of practice settings.
Related Concept Videos
Introduction to Documentation and Reporting
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive and precise...
Purpose of Health Records I
Here's a breakdown of how health records serve these purposes:
Purpose of Health Records II
Methods of Documentation I: Source-Oriented Records
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
Methods of Documentation II: POMR
Methods of Documentation VII: EMR

