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The utility for audit of manual and computerized problem-oriented medical record systems.

Authors: W C, Stratmann; A S, Goldberg; L D, Haugh;

The utility for audit of manual and computerized problem-oriented medical record systems.

Abstract

Objective assessment of the delivery of care requires an unambiguous record of all related events and decisions in the care process. Both the handwritten Problem-Oriented Medical Record (POMR) and its computerized successor, the Problem Oriented Medical Information System (PROMIS) have been designed to facilitate audit of care delivery. In this study, a national sample of physicians was asked to determine which of these two record systems best serves the function of audit. The study involves assessment of a sample of 69 matched pairs of patient records drawn from two different ward settings, one of which used the manual POMR, the other, PROMIS. No difference was perceived between the two records with respect to the reliability of information or the analytical reasoning of providers. Information in PROMIS records was judged to be slightly more thorough. The format of the manual record was judged better on the basis of conciseness, accessibility, and organization of record information.

Keywords

Medical Audit, Systems Analysis, Computers, Medical Records, Problem-Oriented, Medical Records, Information Systems

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Powered by OpenAIRE graph
Found an issue? Give us feedback
selected citations
These citations are derived from selected sources.
This is an alternative to the "Influence" indicator, which also reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Citations provided by BIP!
popularity
This indicator reflects the "current" impact/attention (the "hype") of an article in the research community at large, based on the underlying citation network.
BIP!Popularity provided by BIP!
influence
This indicator reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Influence provided by BIP!
impulse
This indicator reflects the initial momentum of an article directly after its publication, based on the underlying citation network.
BIP!Impulse provided by BIP!
9
Average
Top 10%
Average
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