New concepts in design of medical records in the computer era.

Abstract

A system of medical record storage and retrieval to comply with modern conditions and computer facilities of the future is described. The achievements Include: (i) a unique approach to record Storage; (ii) integration of coding with the narrative; (iii) confidential code extraction for punch carding; (iv) provision for “on line” computer facilities relating to biochemical, pathological and X-ray departments; (v) provision for follow-up of patients when “on line” computer facilities are available; (vi) an open-ended data system available for hort or long term projects, Including annual reports. It is proposed to describe a complete break away from traditional concepts of record design, storage and retrieval of contained data. There is no Intention, however, to limit the clinician's freedom of use of the manuscript record In the case of any current disease event.