Title: A computer-based, communication-oriented medical record

Authors: H.J. Tange, V.A.B. Dreessen, H.H.L.M. Donkers, A. Hasman

Addresses: Department of Medical Informatics, University of Maastricht, The Netherlands. ' Department of Medical Informatics, University of Maastricht, The Netherlands. ' Department of Computer Science, University of Maastricht, The Netherlands. ' Department of Medical Informatics, University of Maastricht, The Netherlands

Abstract: In this contribution, the main characteristics of a prototype computer based medical record system are presented. The system is based on a theory of medical record keeping called the communication-oriented approach. It is described how the theoretical principles are implemented, especially into the database and the user interface. The system offers solutions for three typical problems: the dispute about how to order the content of the medical record, the unsatisfactory documentation of the medical reasoning process, and the controversy on how to structure physician|s narratives. These solutions are discussed in relation to alternative solutions that are described in the literature.

Keywords: medical records; computer-based; problem-oriented; medical reasoning; communication; narrative-data.

DOI: 10.1504/IJHTM.1999.004528

International Journal of Healthcare Technology and Management, 1999 Vol.1 No.3/4, pp.288 - 300

Published online: 21 May 2004 *

Full-text access for editors Full-text access for subscribers Purchase this article Comment on this article