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Computerized medical record in a private neurotology practice
J D Green1, D S Postma, N A Giddings
1Jacksonville Hearing and Balance Institute, Florida, USA.
Objective:
To develop a computerized medical record for a private neurotology practice using a relational database with templates.
Background:
Computers have been used in the medicine many years for billing, scheduling appointments, and word processing. Neurotology represents a relatively narrow field of medicine, which is particularly suited to a computerized record. A computerized medical record should allow for better data storage and retrieval as well as better documentation of the patient care given.
Methods:
Using a commercially available, record-keeping software in a local area computer network. templates were developed for several common neurotologic problems. A template for a neurotologic examination was also developed. These were adapted from templates developed by a group otolaryngology practice in a neighboring city. Data entry templates for vestibular and audiologic tests were also developed. Implementation of the computerized record was accomplished in phases, allowing elimination of the paper record.
Results:
A fully computerized medical record has been developed and maintained in a private neurotology practice over the past year. Patient response to the computerized record system has been favorable. Office personnel have adapted well to a paperless record, and referring physicians have welcomed the documents generated by the computer.
Conclusion:
Computerizing the medical records of a neurotology practice is possible and allows for improved documentation, ongoing assessment of treatment results, and improved efficiency among office staff.