Abstract
Given the many efforts currently under way to develop standards for electronic medical
records, it is important to step back and reexamine the fundamental principles which
should underlie a model of the electronic medical 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 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 Oriented
Medical Record and also relate the criteria to secondary uses of the medical record
for population data, communications and decision support.
Key-Words
Medical Record - Information Models - Standards - Problem-Oriented Medical Record
