Alternatives in Medical Record Formats

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Abstract
Access to information is the ultimate purpose of data storage systems. The medical record is a data storage and retrieval system. Its organization, however, has confounded the purpose of providing accessible data to the physician who must make the clinical decision. Traditional and proposed formats for manual medical information storage are surveyed for features which improve or impede the access-time to clinical data. Time studies demonstrating the effect of different formats upon the task of retrieving standard information from the medical record are presented. With a traditional record in his hand, the physician requires an average of 30 to 40 seconds to answer very simple clinical questions. A medical record with fixed-format, flow sheet organization permits access to certain data in approximately one-fourth the time of other formats, together with a significant improvement in the accuracy of retrieved information. Long access time to clinical data probably results in infrequent use of the traditional record for data retrieval. With more accessible data, information in the record may play a more active part in the clinical decision process.

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