Computerized medical record in a private neurotology practice.
OBJECTIVE
To develop a computerized medical record for a private neurotology practice using a relational database with templates.


BACKGROUND
Computers have been used in the medicine many years for billing, scheduling appointments, and word processing. Neurotology represents a relatively narrow field of medicine, which is particularly suited to a computerized record. A computerized medical record should allow for better data storage and retrieval as well as better documentation of the patient care given.


METHODS
Using a commercially available, record-keeping software in a local area computer network. templates were developed for several common neurotologic problems. A template for a neurotologic examination was also developed. These were adapted from templates developed by a group otolaryngology practice in a neighboring city. Data entry templates for vestibular and audiologic tests were also developed. Implementation of the computerized record was accomplished in phases, allowing elimination of the paper record.


RESULTS
A fully computerized medical record has been developed and maintained in a private neurotology practice over the past year. Patient response to the computerized record system has been favorable. Office personnel have adapted well to a paperless record, and referring physicians have welcomed the documents generated by the computer.


CONCLUSIONS
Computerizing the medical records of a neurotology practice is possible and allows for improved documentation, ongoing assessment of treatment results, and improved efficiency among office staff.
Jacksonville Hearing and Balance Institute, Florida, USA.
J D
JD
Green
D S
DS
Postma
N A
NA
Giddings
K R
KR
Sapp
T
T
Skinner
D006801:Humans; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*; D009462:Neurology; D009816:Office Automation; D009937:Organizational Objectives; D010036:Otolaryngology; D011216:Practice Management, Medical / Q000458:organization & administration; D011331:Private Practice / Q000458:organization & administration*; D012984:Software; D014584:User-Computer Interface