ABSTRACT
Patient care requires communication and documentation. The complexity of patient care
has led to an increase in the amount and detail of information needed to deliver patient
care. As health care delivery requires ever larger patient populations to maintain
cost effectiveness, greater amounts of information need to be exchanged among a larger
group of providers over an expanded geographic area. The computerized medical record
provides a medium for information exchange, communication, storage, and analysis.
Electronic information management has been embraced in business and education, but
has been limited in its integration within health care. Although business and financial
sectors of the health care industry are computerized, these are often separate from
patient care, and as a result the potential benefits of integration are lost. Conversion
of a paper-based medical record to an electronic medical record can result in a paperless
medical record, but the real challenge lies in the implementation of a coordinated
system. The use of a computerized medical record to effect the interaction of the
multiple functioning units that constitute a hospital business is an achievable goal.
KEYWORDS
Medical records systems - computerized organization and administration
