Organizing the clinical data in the medical record.
We have developed a method of collecting and arranging clinical data that makes the medical record more useful in patient care and research. The design is based on two principles: that detailed clinical findings should be recorded independently of any diagnostic interpretation, and that time should be integrated as a dimension of the medical record. Analysis of the principal components of the medical record as we have organized it allows identification of clinical entities on the basis of synchronous or sequential features and facilitates precise tracking of symptoms, evaluation of therapeutic effects, comparison of treatments, identification of patients at risk of recurrence, transmission of observations from physician to physician, and analysis and reinterpretation of the observations recorded.
Bolens
M
M
Borst
F
F
Scherrer
J R
JR
D000553:Ambulatory Care; D003625:Data Collection / Q000379:methods*; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000639:trends*; D010372:Pediatrics