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PubMed · 6688264

A chartless record--is it adequate?

W W Stead·W E Hammond·M J Straube
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Abstract

The computerized medical record supported by The Medical Record (TMR) has been the only record of physician-patient encounters on the nephrology service of the Durham Veterans Administration Medical Center since April 1981. Physicians using the system evaluated the adequacy of the computerized record as a replacement for the paper chart. The computerized record was able to capture and display all pertinent data. Manual or computerized narratives provided a useful supplement to the core computerized record only in those rare instances that a physician needed to point out which of the data in the record were important to his decision making.

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ComputersEvaluation Studies as TopicHospital Bed Capacity, 300 to 499Hospital RecordsNephrologyNorth CarolinaOutpatient Clinics, HospitalRecordsSoftwareJournal Article

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W W Stead, W E Hammond, M J Straube. 1983. A chartless record--is it adequate?. https://doi.org/10.1007/bf00995117

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