The Computerized Medical Record

ABSTRACT

Patient care requires communication and documentation. The complexity of patient care has led to an increase in the amount and detail of information needed to deliver patient care. As health care delivery requires ever larger patient populations to maintain cost effectiveness, greater amounts of information need to be exchanged among a larger group of providers over an expanded geographic area. The computerized medical record provides a medium for information exchange, communication, storage, and analysis. Electronic information management has been embraced in business and education, but has been limited in its integration within health care. Although business and financial sectors of the health care industry are computerized, these are often separate from patient care, and as a result the potential benefits of integration are lost. Conversion of a paper-based medical record to an electronic medical record can result in a paperless medical record, but the real challenge lies in the implementation of a coordinated system. The use of a computerized medical record to effect the interaction of the multiple functioning units that constitute a hospital business is an achievable goal.

KEYWORDS

Medical records systems - computerized organization and administration

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