Shuval automated problem-oriented record: an off-line record for a primary care clinic

Area of Science:

• Health Informatics
• Medical Record Systems

Background:

• Traditional medical records can be time-consuming to manage and analyze.
• Problem-oriented records enhance patient care by focusing on specific health issues.
• The need for cost-effective, automated record-keeping solutions in healthcare is growing.

Purpose of the Study:

• To describe an off-line system for automating the problem-oriented medical record.
• To evaluate the efficiency and analytical capabilities of the automated system.

Main Methods:

• Implementation of the Shuval problem-oriented record system, including acute/chronic problem lists, patient/nurse data collection, plan flow sheets, progress notes, and record audits.
• Development of a three-form data processing system for the automated record.
• Analysis of data transfer times and types of analyses performable.

Main Results:

• The mean conversion time from traditional to problem-oriented records was 17 minutes for children and 25 minutes for adults.
• Automated data transfer averaged 10 minutes for a child's record (range: 5-30 minutes).
• The system supports administrative, patient care, epidemiologic, demographic, and clinical research analyses.

Conclusions:

• The Shuval automated problem-oriented record system provides significant advantages of online systems at a reduced cost.
• This off-line system offers a practical and economical solution for enhancing medical record management and analysis.