A new format for the medical record.
Over the centuries, the medical record has become stereotyped. Reconsidering the purpose and organization of this document leads me to propose a four-part format consisting of administrative data, a patient synopsis, a chronological medical record, and a detailed medical record. The patient would be identified only in the administrative data section, leaving the rest of the record available for management, outcome, and cost studies, and protecting the patient's privacy. Adoption of this four-part format would make it easier to locate information in the medical record and would facilitate computerization. If the phraseology could be standardized, the new format would also allow easier data flow from one medical record to another and permit the construction of standardized disease profiles. Data on individual patients could then be compared with standardized profiles to identify deficiencies and redundancies in patient care.
Department of Medicine, Erie County Medical Center, Buffalo, NY 14215.
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Bishop
D003219:Confidentiality; D003628:Database Management Systems; D016347:Medical Records Systems, Computerized / Q000592:standards; D011381:Programming Languages; D009626:Terminology as Topic