An Automated Medical Record System

Abstract

An automated medical record system for ambulatory care has been developed for a prepaid group practice. It has been operational for two years, maintaining the medical records for 20,000 people who have made a total of 80,000 visits. The principal data source is a structured encounter form that is filled out by the care provider at the time of each visit. From these data, a progress note and an updated summary of the patient's medical status are generated by the computer. The same system also produces the aggregate statistics necessary for administration and evaluation. The unique characteristic of this medical information system is its ability to meet, at a reasonable cost, the data needs of both patient care and administration. The potentials of the system for facilitating patient management, evaluation, and planning are also seen as important attributes of this approach.