Physician utilization of medical records: preliminary determinations.
A study is reported of the ways in which 26 physicians, mostly internists, use the medical record. It was found that the items of greatest importance to the physicians, from the viewpoints of frequency of usage and of occasional interruption of the physician-patient transaction by being absent, were lab-test results, X-ray data, patient history, and previous treatments. The most common general problems cited uith the medical record were incompleteness (named by 38 per cent of the physicians), illegibility (27 per cent), and poor organization of the record (19 per cent).
D006801:Humans; D007388:Internal Medicine; D008487:Medical History Taking; D008499:Medical Records; D014481:United States