Half a loaf is better than waiting for the bread truck. A computerized mini-medical record for outpatient care

Abstract

We describe a locally developed system for partial computer storage of medical data, called the mini-medical record system. The system produces a typed face sheet prior to each patient visit. The face sheet, which also serves as a progress note, contains patient demographic data, medical problem lists, previous vital signs, allergies, medication profile, and health maintenance reminders. Between regularly scheduled visits, all computerized data are available by computer printout for unscheduled visits to walk-in clinics and the emergency department. Structured reports are generated by the system that describes each resident and faculty members' practice. Quality assurance reports are also available. Since the system draws from several already existing databases, new data entry requirements are modest and cost to the institution is low. Partially computerized systems can be developed inexpensively and are well received in multispecialty practices, where interphysician communication is vital.