[Evaluation of computerized medical records].
BACKGROUND
A wide and expensive supply of electronic medical records obliged us to evaluate them before selecting one. In this study a questionnaire was used to evaluate computerized medical records.


METHODS
Descriptive and prospective study with personal interviews in which a questionnaire was used, that had been previously published.


RESULTS
The 12 questionnaires were completed in 99%. The greatest difficulty for answering the questions was the medical terminology. Four of the twelve computer programs were designed for hospitals, another 4 were designed for health centers and the rest were designed for both hospitals and health centers. The preventive and social data and annex were the more scarce of the elements (47%). Postsells services (100%), the ICE-9-CM classification (75%) and medicals data (51%) were the more frequent elements.


CONCLUSIONS
In Spain there are few medical records regulated, and computerized designers do not have a standard model. The sellers of medical record softwares don't have knowledge of medical terminology. Medical record software programs are not designed for specific health settings (health centers or hospitals).
Pastor-Sánchez
R
R
Equipo CESCA, Consultorio San Francisco de Paula Area IV (INSALUD), Madrid.
López-Miras
A
A
Gérvas
J
J
D005069:Evaluation Studies as Topic; D016347:Medical Records Systems, Computerized; D011446:Prospective Studies; D011795:Surveys and Questionnaires
Evaluación de historias clínicas informatizadas.