Computerized medical records. A new resource for clinical decision making

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Updated: Aug 4, 2026

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Published on: September 26, 2018

W W Stead, W E Hammond

    Journal of Medical Systems
    |June 1, 1983
    PubMed

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    Purpose of Health Records I01:11

    Purpose of Health Records I

    The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
    Here's a breakdown of how health records serve these purposes:
    Purpose of Health Records II01:19

    Purpose of Health Records II

    Health records serve various essential purposes in the healthcare system. Here are some key purposes:
    Methods of Documentation II: POMR01:26

    Methods of Documentation II: POMR

    The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.
    Methods of Documentation VII: EMR01:30

    Methods of Documentation VII: EMR

    Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare settings,...
    Health Information Technology and Healthcare Information System01:30

    Health Information Technology and Healthcare Information System

    Health Information Technology (HIT)
    Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
    Nursing Clinical Information System01:27

    Nursing Clinical Information System

    Nursing Clinical Information System (NCIS)
    A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
    Critical attributes of NCIS include: