A multi-strategy approach for medical records of specialists.
Despite a number of well recognized shortcomings of paper medical records, the use of Computer Patient Records (CPR) is not widespread among specialists. The complexity of specialized care combined with the diversity of their domains of expertise make it a challenge to design a CPR that satisfies the needs of a specialist. Ideally, CPRs are tailored to the specific tasks of each user, yet general enough to permit the exchange and sharing of information. The basic philosophy behind our CPR is a "mother" record, extended with specialized sub-records. Two different types of subrecords are discussed: one to accommodate standardized data entry in the context of a specialty or research protocol, and another for structured recording of accidental findings outside one's own domain of expertise. The CPR does not impose structured data entry on the physician, but stimulates her to do so by confronting her with the benefits of a structured CPR.
van Ginneken
A M
AM
Department of Medical Informatics, Erasmus University, 3000 DR Rotterdam, The Netherlands.
Stam
H
H
Moorman
P W
PW
D008499:Medical Records; D016347:Medical Records Systems, Computerized; D008511:Medicine; D013038:Specialization