A strategy for redesigning the medical record for quality assurance.
The medical record should be viewed as an instrument to facilitate and demonstrate the achievement of explicit health care goals. Current systems do not accomplish this. Our examination of the traditional record suggests that modifications of the record should be based on the principles of information system design theory. Necessary modifications include changes which prompt the monitoring of the outcome parameters of a patient's illness, encourage the analysis of the patient's outcome, and facilitate adaptive (corrective) actions. We have termed those data elements which describe the achievement of patient-specific, problem-specific objectives as the "minimum care assurance data set." To designers of computerized medical information systems, this approach provides a rationale for selecting which data to place in computer storage from the myriad of detail in the traditional paper record.
D003201:Computers; D006801:Humans; D008499:Medical Records / Q000592:standards*; D011786:Quality Control; D011787:Quality of Health Care; D013597:Systems Analysis