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Organizing the clinical data in the medical record
M.D. Computing : Computers in Medical Practice
|May 1, 1992
Summary
We created a new clinical data collection method to improve patient care and research. This approach separates findings from interpretations and integrates time, enhancing medical record utility.
Area of Science:
- Clinical Informatics
- Medical Record Management
- Health Data Science
Background:
- Traditional medical records often intertwine clinical findings with diagnostic interpretations.
- Integrating temporal data into medical records is crucial for comprehensive analysis.
Purpose of the Study:
- To develop an improved method for collecting and organizing clinical data.
- To enhance the utility of medical records for both patient care and research.
Main Methods:
- Recording detailed clinical findings independently of diagnostic interpretation.
- Integrating time as a fundamental dimension within the medical record structure.
Main Results:
- The organized medical record facilitates identification of clinical entities based on temporal features.
- Enables precise tracking of symptoms, evaluation of treatments, and risk assessment for recurrence.
Conclusions:
- This method enhances medical record utility for clinical care and research.
- Improves physician-to-physician communication and allows for reinterpretation of recorded observations.
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