Computerized medical records: defining a standard without the computer.

Abstract

The inevitable computerization of medical records may be a boon or a hindrance to the practice of medicine. A comprehensive view of the project is essential for its success. Definite goals for the computerized medical record are stated to this end. An argument is presented for keeping the structure of the medical record separate from any specific requirements of technology. An elegant structure for medical records is proposed, independent of any computer system and requiring a minimum of definitions or special characters. The roles of clinical specialists (such as physicians and nurses), medical records specialists, administrators, accountants, and computer architects (hardware and software) are defined. In particular, the tasks of lexicon and template creation are defined and emphasized as urgent and ongoing challenges for specialty organizations.