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Related Experiment Videos

The computer-based medical record: current status.

S M Ornstein1, R B Oates, G N Fox

  • 1Department of Family Medicine, Medical University of South Carolina, Charleston 29425-5820.

The Journal of Family Practice
|November 1, 1992
PubMed
Summary
This summary is machine-generated.

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The evolution of medical records from paper to electronic systems addresses limitations and improves healthcare quality. Electronic medical records offer decision support and data for research, paving the way for widespread computerization.

Area of Science:

  • Medical Informatics
  • Health Information Systems
  • Clinical Documentation

Background:

  • Historically, clinical records were not routinely maintained by hospitals or physicians.
  • The paper-based medical record has demonstrated inadequacies with increasing societal and medical complexity.
  • The transition to computer-based systems is driven by the need for improved data management and quality verification.

Purpose of the Study:

  • To review the historical evolution of medical records.
  • To highlight the advantages of computer-based medical records over paper records.
  • To discuss the current trends and future of electronic medical records in healthcare settings.

Main Methods:

  • Literature review of the historical development of medical records.

Related Experiment Videos

  • Analysis of the deficiencies of paper-based records.
  • Examination of the decreasing barriers to computer-based record adoption (hardware affordability, software refinement).
  • Discussion of societal and payer demands for quality and effectiveness verification.
  • Case study of computer-based clinical record systems in two family practice settings.

    • Main Results:

    • Computer-based medical records address many deficiencies of paper records.
    • Decreased hardware costs and improved software have reduced barriers to adoption.
    • Electronic medical records can enhance care quality through decision support and data for research.
    • Standardization efforts are underway for computer-based medical information systems.

    Conclusions:

    • The electronic medical record is a crucial step in the evolution of clinical documentation.
    • Forces such as technological advancement and payer demands are driving the computerization of clinical records.
    • Computer-based systems offer significant potential for improving healthcare quality and efficiency.