by A. L. Rector, A. L. Rector, W. A. Nolan, W. A. Nolan, S. Kay, S. Kay
http://www.cs.man.ac.uk/mig/ftp/pub/papers/alr-foundations.pdf
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Abstract:
Abstract: Given the many efforts currently under way to develop standards for medical records, it is important to step back and re-examine the fundamental principles which should underlie a model of the electronic 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 must 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-Orientated Medical Record and also relate the criteria to secondary uses of the medical record for population data, communications and decision support.
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