Maintenance of a computerized medical record form

Structured entry forms for clinical records should be updated to take into account the physicians' needs during consultation and advances in medical knowledge and practice. We updated the computerized medical record form of a hypertension clinic, based on its previous use and clinical guidelines. A statistical analysis of previously completed forms identified several unnecessary items rarely used by clinicians. A terminological analysis of guidelines and of free-text answers on completed forms identified several new topics relevant to current clinical practice. We therefore added new items to the form and some topics previously recorded as free text were itemized. We collaborated with clinicians in interpretation of the results of the statistical and terminological analyses used as the starting point and guide for this updating process.