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Foundations for an Electronic Medical Record (1991)
| Citations: | 17 - 5 self |
BibTeX
@MISC{Rector91foundationsfor,
author = {A. L. Rector and A. L. Rector and W.A. Nolan and W. A. Nolan and S. Kay and S. Kay},
title = {Foundations for an Electronic Medical Record},
year = {1991}
}
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Abstract
: Given the many efforts currently under way to develop standards for medical records, it is important to step back and re-examine the fundamental principles which should underlie a model of the electronic record. This paper presents an analysis based on the experience in developing the PEN & PAD prototype clinical workstation. The fundamental contention is that the requirements for a medical record must be grounded in its use for patient care. The basic requirement is that it must be a faithful record of what clinicians have heard, seen thought, and done. The other requirements for a medical record, e.g., that it be attributable and permanent, follow naturally from this view. We use the criteria developed to re-examine Weed's Problem-Orientated Medical Record and also relate the criteria to secondary uses of the medical record for population data, communications and decision support. Key-Words: Medical Record, Information Models, Standards, Problem-Orientated Medical Record. Introdu...
Keyphrases
medical record electronic medical record problem-orientated medical record population data fundamental contention basic requirement secondary us pen pad prototype clinical workstation decision support many effort electronic record patient care re-examine weed fundamental principle faithful record information model
