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At least 19 recordsLinked to original sources
PubMed1977

An integrated medical record and data system for primary care. Part 1: the age-sex register: definition of the patient population.

This is the first of series of articles which describes an integrated system for recording medical data. The age-sex register is described in detail. Uses of the register include enhanced capabilities for office management, assessment of postgraduate educational needs, outreach, audit, and research. The problems encountered with definition of the practice size are discussed. Subsequent articles will describe a classification of health problems, a diagnostic index, family folders, filing patients records by geographic location, problem-oriented medical records, encounter forms, and various record forms.

Age Factors↗
PubMed1977

An integrated medical record and data system for primary care. Part 8: the individual patient's medical record.

This is the last in a series of eight articles describing an integrated system of recording medical data as developed and used by the Family Medicine Program at the University of Rochester-Highland Hospital. Compatability of manual and automated systems has been described. The total system allows the practicing family physician to assess morbidity patterns within his/her practice more effectively, to record and monitor patient care, to perform audit, and to conduct research in primary care.

Humans↗
PubMed1978

Will your medical records get you into trouble?

Medical records frequently become legal documents. They can be the physician's best friend or worst enemy, depending on how the healthy care provider has maintained and cared for the record. Medical records that are properly maintained, including those that have properly made changes, can turn out to be a physician's staunchest ally. One cannot hope to rely on the support of a friend when the relationship has been tampered with. The health care provider has the duty to properly maintain the custody of the record, protecting the patient's right to confidentiality.

Confidentiality↗
PubMed1977

An integrated medical record and data system for primary care. Part 6: a decade of problem-oriented medical records: a reassessment.

The Problem-Oriented Record (POR) has had a profound effect upon the medical community. Since its introduction not quite ten years ago, POR has gained remarkable acceptance. A short review of the relatively brief history of POR is given and various facets of its use are outlined as guidelines for more critical reappraisal of its merits. The fact, however, that POR is currently taught in a majority of medical schools and used in ever increasing numbers of hospitals is highly indicative of eventual conversion of all medical recoreds to POR format.

Diagnosis↗
PubMed1975

A rehabilitation evaluation system which complements the problem-oriented medical record.

The traditional medical history and physical examination format is disease rather than disability oriented. It has been shown to be incomplete for the total evaluation of rehabilitation patients. Direct applications of Weed's Problem-Oriented Medical Record have proven to be formidable and cumbersome due to the complexity and diversity of rehabilitation. Therefore, we have developed the Rehabilitation Evaluation System (RES) to document functional rehabilitation management and progress during inpatient hospitalization and outpatient follow-up. The system identifies 18 key rehabilitation areas, each with an individual and objective four-point scale. Utilization of this system in our department has been invaluable in formulating goals and continually evaluating the on-going rehabilitation process. We used the RES with equal facility on 46 rehabilitation inpatients including stroke, amputation, spinal cord injury, multiple sclerosis, orthopedic-trauma, rheumatoid arthritis and poliomyelitis. The mechanics of the RES are presented in detail with a specific patient-example of hemiplegia. Its complimentary use with the Problem-Oriented Medical Record is discussed. Practical advantages are seen in patient care, medical student and resident education, record keeping and research.

Disability Evaluation↗
PubMed1979

Medical records--legal perspectives.

Good documentation of medical diagnosis and treatment is not only a medical necessity, it is a legal one. Whether the physician is innocent or guilty of malpractice quickly becomes a side issue when it is discovered that he has tampered with the evidence, thereby attempting to perpetrate a fraud upon the court. And discovered it will be--the techniques are sophisticated and the motivation is high. Medical records are also important in workman's compensation cases, insurance claims, personal injury cases, and even in physician disciplinary hearings as well as their collection of bills. In creating and maintaining patient records, physicians and hospitals have several legal duties, including the duty to do so adequately, to safeguard the records' physical existence, and to prevent such use of the records as would violate the patient's right to confidentiality. Courts and legislatures are looking with increasing favor on the patient's interest in the content of his record, a phenomenon which is closely linked to the nationwide trend in favor of the patient's right to know and his right to determine his own physical destiny. For all these reasons, medical records no longer serve exclusively as the physician's private aid; medical records are increasingly becoming legal documents as well.

Confidentiality↗
PubMed1977

Development of a medical record audit for continuing medical education.

A self-instructional audit package for the identification and management of hypertensive patients was developed. The materials were field tested in the clinics of seven institutions to assess their clarity and collect data to illustrate the usefulness of an audit as an educational tool.

Ambulatory Care↗