Family Medicine pp 1789-1803 | Cite as

The Medical Record

  • Herbert T. Smith


Recently a family practice resident returned from a 2-month rural preceptorship, and his evaluation of the physician and his practice was as follows: “I had the opportunity to see a lot of patients and pathology, and do a lot of family practice you don’t see in a city, but the way the doctor ran his office and his medical record system was mayhem.” The resident was saying, in effect, “The practice was running the physician, rather than the physician running the practice.”


Family Physician Family Practice Progress Note Problem List Practice Population 
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  1. 1.
    Manning PR: The problem-oriented record as a tool in management. Clin Obstet Gynecol 18: 175–179, 1975.PubMedCrossRefGoogle Scholar
  2. 2.
    Walker HK: Commentary: the problem oriented-medical system. JAMA 236: 2397–2798, 1976.PubMedCrossRefGoogle Scholar
  3. 3.
    Grace NT, Neal EM, Wellock CE, Pile DD: The family-oriented medical record. J Fam Pract 4: 91–98, 1977.PubMedGoogle Scholar
  4. 4.
    Jackson CB Jr, Drueger DE, Densen PM: Ambulatory care medical records: uniform minimum basis data set. JAMA 243: 1245–1247, 1975.CrossRefGoogle Scholar
  5. 5.
    Brandijs JF, Kasowski MA, Fortin LJ: Information sys tems. VII. Problem-oriented medical records for family practice. Cau Med Assoc J 114: 371–394, 1976.Google Scholar
  6. 6.
    Rakel RE: The problem-oriented medical record (POMR). Am Fam Physician 10 (3): 100–111, 1972.Google Scholar
  7. 7.
    Bass MJ, Newell FP, Dickie GL: An information system for family practice. I. Defining the practice population. J Fam Pract 3: 517–520, 1976.PubMedGoogle Scholar
  8. 8.
    Bass MJ, Newell JP, Dickie GL: An information system for family practice. II. The value of defining a practice population. J Fam Pract 3: 525–530, 1976.PubMedGoogle Scholar
  9. 9.
    Thompson HC, Osborne CE: Office records in the evaluation of quality of care. Med Care 14: 294–314, 1976.PubMedCrossRefGoogle Scholar
  10. 10.
    Robbins LC, Hall JH: How to Practice Prospective Medicine. Indianapolis, Methodist Hospital of Indiana, 1970.Google Scholar
  11. 11.
    Ladou J, Sherwood JM, Hughes L: Health hazard appraisal in patient counseling (preventive medicine). West J Med 122: 177–180, 1975.PubMedGoogle Scholar
  12. 12.
    McCulloch W: Prospective medicine-improving the patient’s survival odds. Am Med News 9: 21, 1974.Google Scholar
  13. 13.
    Dinsdale SM, Gent M, Kline G, Milner R: Problem-oriented medical records: their impact on staff communication, attitudes and decision-making. Arch Phys Med Rehabil 56: 269–274, 1975.PubMedGoogle Scholar
  14. 14.
    Fujikawa LS: Family care in a family practice group. J Fam Pract 5: 1189–1194, 1977.Google Scholar
  15. 15.
    Jolly W, Froom J, Rosen ME: The genogram. J Fam Pract 10: 251–255, 1980.Google Scholar
  16. 16.
    Driggs MF: Problem-Directed and Medical Information Systems [selected papers and discussion from the fourth annual scientific meeting of the Society for Advanced Medical Systems (SASM) held in Saddle Brook, NJ]. New York, Intercontinental Medical Book Corporation, 1973.Google Scholar
  17. 17.
    Fries JF: Alternatives in medical record formats. Med Care 12: 871–881, 1974.PubMedCrossRefGoogle Scholar
  18. 18.
    Tharp R: Records that let me see 50 percent more patients. Med Econ 2: 72–79, 1976.Google Scholar
  19. 19.
    The National Ambulatory Medical Care Survey: Symptom Classification, DHEW Publication No. (HRA) 74. Rockville, MD, US Department of Health and Welfare, Public Health Service, Health Resources Administration, National Center for Health Statistics, 1974.Google Scholar
  20. 20.
    Barnett GO. COSTAR: Computer-Stored Ambulatory Report-A Progress Report. Boston, Massachusetts General Hospital, 1978.Google Scholar
  21. 21.
    Dickie GL: Improving problem oriented medical records through self-audit. J Fam Pract 10 (3): 487–490, 1980.PubMedGoogle Scholar
  22. 22.
    Geyman JP: How effective is patient education? J Fam Pract 10: 973–974, 1980.PubMedGoogle Scholar
  23. 23.
    Paymond S: Criteria in the choice of a computer system. II. The computer in practice. JAMA 228: 1015–1017, 1974.CrossRefGoogle Scholar
  24. 24.
    Ludwig H: Computer Applications and Techniques in Clinical Medicine. New York, Wiley, 1974.Google Scholar
  25. 25.
    Morrison CC: The computer in family practice. J Maine Med Assoc 10: 56–60, 1973.Google Scholar
  26. 26.
    Payne RF: The computer as a tool in clinical medicine. South Med J 64: 1216–1220, 1971.PubMedCrossRefGoogle Scholar
  27. 27.
    Brandeis JF, Kasowski MA, Doyle CE: Information systems. III. Methodology and long-term applications. Can Med Assoc J 113: 1006–1007, 1975.Google Scholar
  28. 28.
    Mesel E, Wirtschafter DD: On-line medical billing system for physicians’ services. Comput Boimed Res 8: 487–491, 1975.Google Scholar
  29. 29.
    Mesel E, Wirtschafter DD: Automation of a patient medical profile from insurance claims data: a possible first step in automation ambulatory medical records on a national scale. Milbank Mem Fund Q Health Soc, Winter 1976, p. 29.Google Scholar
  30. 30.
    Luff CA, Walker PC: A computer code for the recording of patients’ problems. Comput Biomed Res 8: 267, 1975.PubMedCrossRefGoogle Scholar
  31. 31.
    Newell JP, Dickie GL, Bass MJ: An information system for family practice. 3. Gathering encounter data. J Fam Pract 3: 633–636, 1976.PubMedGoogle Scholar
  32. 32.
    McDonald CJ: Use of a computer to detect and respond to clinical events: its effect on clinician behavior. Intern Med 84: 162–167, 1976.CrossRefGoogle Scholar
  33. 33.
    Taylor RB: Family: a systems approach. Am Fam Physician 20 (5): 101–104, 1980.Google Scholar

Copyright information

© Springer Science+Business Media New York 1983

Authors and Affiliations

  • Herbert T. Smith

There are no affiliations available

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