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| Predicate | Object |
|---|---|
| rdf:type | |
| lifeskim:mentions | |
| pubmed:issue |
3
|
| pubmed:dateCreated |
1991-12-4
|
| pubmed:abstractText |
Given the many efforts currently under way to develop standards for electronic medical records, it is important to step back and reexamine the fundamental principles which should underlie a model of the electronic medical record. This paper presents an analysis based on the experience in developing the PEN & PAD prototype clinical workstation. The fundamental contention is that the requirements for a medical record must be grounded in its use for patient care. The basic requirement is that it be a faithful record of what clinicians have heard, seen, thought, and done. The other requirements for a medical record, e.g., that it be attributable and permanent, follow naturally from this view. We use the criteria developed to re-examine Weed's Problem Oriented Medical Record and also relate the criteria to secondary uses of the medical record for population data, communications and decision support.
|
| pubmed:language |
eng
|
| pubmed:journal | |
| pubmed:citationSubset |
IM
|
| pubmed:status |
MEDLINE
|
| pubmed:month |
Aug
|
| pubmed:issn |
0026-1270
|
| pubmed:author | |
| pubmed:issnType |
Print
|
| pubmed:volume |
30
|
| pubmed:owner |
NLM
|
| pubmed:authorsComplete |
Y
|
| pubmed:pagination |
179-86
|
| pubmed:dateRevised |
2006-11-15
|
| pubmed:meshHeading | |
| pubmed:year |
1991
|
| pubmed:articleTitle |
Foundations for an electronic medical record.
|
| pubmed:affiliation |
Department of Computer Science, University of Manchester, U.K.
|
| pubmed:publicationType |
Journal Article,
Research Support, Non-U.S. Gov't
|