H. Phelps Potter Jr., MD
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To the Editors: Shortliffe and colleagues (1) cite the faults of today's medical records and suggest computerization as the solution. However, computerization would necessitate changes in record structure and volume.
The traditional hospital and office record format would have to be replaced by a problem-oriented model of the type suggested by Weed (2). Problem-oriented hospital discharge summaries and updated office problem lists provide a compact database for subsequent effective management. The current dictum that "if it's not in the record, it wasn't done" swells charts with excessive documentation that is unnecessary for patient care and generally superfluous for future quality
Potter HP. Computerizing Patient Records. Ann Intern Med. 1992;116:959. doi: 10.7326/0003-4819-116-11-959_1
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Published: Ann Intern Med. 1992;116(11):959.
DOI: 10.7326/0003-4819-116-11-959_1