A chartless record--is it adequate?
The computerized medical record supported by The Medical Record (TMR) has been the only record of physician-patient encounters on the nephrology service of the Durham Veterans Administration Medical Center since April 1981. Physicians using the system evaluated the adequacy of the computerized record as a replacement for the paper chart. The computerized record was able to capture and display all pertinent data. Manual or computerized narratives provided a useful supplement to the core computerized record only in those rare instances that a physician needed to point out which of the data in the record were important to his decision making.
D003201:Computers; D005069:Evaluation Studies as Topic; D006745:Hospital Bed Capacity, 300 to 499; D006753:Hospital Records; D009398:Nephrology; D009657:North Carolina; D010044:Outpatient Clinics, Hospital / Q000458:organization & administration*; D011996:Records; D012984:Software