Medical records: past, present, and future

This paper considers the lessons learnt during the development of the electronic medical record for patient care. It is not a definitive history of medical records but an assessment of what has been learnt, what has to be learnt and how we can move forward. It considers the needs for structured intelligent records that help in individual patient care, the need to provide functionality that fits with the requirements of the clinician-patient interaction and the need to take into account the human factors that affect clinician's uptake of such systems. It outlines the issues of free form input as opposed to controlled input that have to be resolved.