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Related Experiment Videos

A chartless record--is it adequate?

W W Stead, W E Hammond, M J Straube

    Journal of Medical Systems
    |April 1, 1983
    PubMed
    Summary
    This summary is machine-generated.

    The Medical Record (TMR) system effectively replaced paper charts for nephrology physician-patient encounters, capturing all essential data. Supplemental narratives were rarely needed for critical data interpretation.

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    Area of Science:

    • Nephrology
    • Medical Informatics
    • Health Information Systems

    Background:

    • The Durham Veterans Administration Medical Center's nephrology service has utilized The Medical Record (TMR) system since 1981.
    • TMR serves as the sole record for physician-patient encounters.

    Purpose of the Study:

    • To evaluate the adequacy of the computerized medical record (TMR) as a replacement for traditional paper charts.
    • Assess the system's ability to capture and display all pertinent patient data.

    Main Methods:

    • Physicians using the TMR system provided evaluations of its effectiveness.
    • Analysis of data capture and display capabilities of the computerized record.

    Main Results:

    • The TMR system successfully captured and displayed all pertinent data for nephrology encounters.

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  • Physicians found the computerized record adequate for routine data management.

    • Conclusions:

    • The Medical Record (TMR) system is a capable replacement for paper charts in nephrology.
    • Manual or computerized narratives were infrequently required to highlight critical data for decision-making.