Computer-Based Patient-Record Systems

The preceding chapters introduced the conceptual basis for the field of medical informatics, including the use of patient data in clinical practice and research. We now focus attention on the patient record, commonly referred to as the patient’s chart or medical record. The patient record is an amalgam of all the data acquired and created during a patient’s course through the healthcare system. The use of medical data was covered extensively in Chapter 2. We also discussed the limitations of the paper record in serving the many users of patient information. In this chapter, we examine the definition and use of computer-based patient-record systems, discuss their potential benefits and costs, and describe the remaining challenges to address in their dissemination.