Mark J. Straube

A Chartless Record—Is It Adequate?

The computerized medical record supported by The Medical Record (TMR) has been the only record of physician-patient encounters on the nephrology service of the Durham Veterans Administration Medical Center since April 1981. Physicians using the system evaluated the adequacy of the computerized record as a replacement for the paper chart. The computerized record was able to capture and display all pertinent data. Manual or computerized narratives provided a useful supplement to the core computerized record only in those rare instances that a physician needed to point out which of the data in the record were important to his decision making.

Adapting to the Dag to Day Growth of TMR

Data capacity requirements vary widely as user groups vary in their use of an dependence on a computerized medical record. The development of TMR has fortunately been able to satisfy growth demands by adapting either application programs or system programs to remove growth restrictions as they are identified. This paper describes that evolution.