Fishing through patient records.

Abstract

Information recording and retrieval in patient records is expensive, painful, and inadequate. Automated hospital systems will undoubtedly provide solutions to these problems, but those solutions are costly and years away. From a practical standpoint, records can be improved today using problem-oriented approaches to patient care and new formats for both subjective and objective information. These points are discussed, and examples of a clinical laboratory data sheet and an intensive care unit record are presented and compared with current procedures at one Boston hospital. CURRENT MEDICAL RECORDS are inadequate. The basic difficulty is the growth of patient charts, both figuratively and literally, like topsy from a carry-over into medical practice of compulsive long narrative formats learned in medical school. The purpose of this paper is to outline some of the problems with current records and the difficulties in providing full scale computerization of patient data. A practical alternative is offered which may be made quite compatible with future automated hospital data processing systems.