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Foundations for an electronic medical record.

A L Rector1, W A Nowlan, S Kay

  • 1Department of Computer Science, University of Manchester, U.K.

Methods of Information in Medicine
|August 1, 1991
PubMed
Summary
This summary is machine-generated.

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This study reevaluates electronic medical record (EMR) principles, emphasizing faithful patient care documentation. It proposes that EMR requirements should stem from clinical use, ensuring accurate records for care, attribution, and permanence.

Area of Science:

  • Medical Informatics
  • Health Information Systems
  • Clinical Documentation

Background:

  • Ongoing development of electronic medical record (EMR) standards necessitates re-examining foundational principles.
  • The PEN & PAD prototype clinical workstation experience informs this analysis.

Purpose of the Study:

  • To re-evaluate the fundamental principles for an electronic medical record model.
  • To ground EMR requirements in their primary use for patient care.

Main Methods:

  • Analysis based on the development of the PEN & PAD prototype clinical workstation.
  • Developing criteria for EMR requirements grounded in clinical use.
  • Re-examining Weed's Problem-Oriented Medical Record using developed criteria.

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Main Results:

  • The core requirement for an EMR is to be a faithful record of clinical encounters (heard, seen, thought, done).
  • Attributability and permanence are natural consequences of a faithful record.
  • The criteria are applicable to secondary EMR uses like population data, communication, and decision support.

Conclusions:

  • EMR design must prioritize accurate and faithful documentation of patient care.
  • A patient-care-centric approach provides a robust foundation for EMR standards.
  • The proposed principles enhance the utility of EMRs for both primary care and secondary data applications.