Improving the medical record for clinical oncology research by adaptation to a microcomputer

In clinical oncology, much of the research is conducted in the milieu of patient care and the traditional medical record is used for collection of data. A clinical study manager reviewing medical records is frequently faced with problems such as omissions of data, illegible notes, and inconsistent locations of data within the various formats. At the Children's Hospital in Birmingham, Alabama, we developed a microcomputer-based medical record system in an attempt to improve the quality of clinical research. Our system is based within our division and provides for a single point of transcription of clinical data when the patient is initially seen. Our entire practice is managed on the system, with numerous reports available that range from individual patient information to summary reports on protocol studies.