The general medical record. Concepts and suggestions for implementation.
Our view of a general medical record consists of a combination of distinct departmental- and specialty-specific medical records and an organizing kernel that contains arguably critical information. Because this system allows each clinical entity to evolve its own system, clinical priorities do not have to be negotiated or compromised. Additionally, subsystem or departmental medical records can be easily revised without disturbing the general medical record because of the modular design. Although the system seems robust with respect to design considerations, only implementation can provide adequate tests.
Nagey
D A
DA
Department of Obstetrics and Gynecology, University of Maryland School of Medicine, Baltimore 21201.
Blackman
J A
JA
Wright
J N
JN
D015982:Bias; D003219:Confidentiality; D006272:Health Facility Environment; D006748:Hospital Departments; D006751:Hospital Information Systems / Q000458:organization & administration*; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*; D017146:Models, Organizational; D009937:Organizational Objectives; D010348:Patient Care Team / Q000458:organization & administration; D011367:Professional Staff Committees; D012985:Software Design