There are two ubiquitous audiences for "medical records" information.
1: administrative/billing/government - who need "demographic"
information, including insurors, indentifications, location, next of
kin, phone numbers, etc.
2: clinicians - who need medication allergies, immunity status, health
"maintenance" history, active "problems" narrative of significant recent
and past medical events (those with residual consequences), and
narrative descriptions of pathology specimens, surgical procedures, and
imaging studies (images are the frosting).
3: research use is not ubiquitously important, but should not be
neglected in planning record structure and contents.
On Mon, 2003-06-16 at 15:00, Richard Schilling wrote:
> I see the same concern with my docs here. How would a simple list of
> patient address/telephone, previous doctors, contacts, medications, and
> selected diagnoses work (e.g. heart disease history)?
>
> Just having the patient's address and telephone available might save
> your office staff about 5-10 minutes of time on each patient.
>
> --Richard
>
>
> On 2003.06.16 07:56 Daniel L. Johnson wrote:
> > On Fri, 2003-06-13 at 21:43, Richard Schilling wrote:
> > >
> > > This thread points out the variety of problems that naturally arise
> > for
> > > a given hardware solution - ...
> > >
> > > If memory serves me correctly (no pun intended), the hospital where
> > I
> > > worked at (1,200 employees) between 1996 and 2000 generated about
> > > 20MB-30MB per outpatient per year. Inpatients have quite a bit more
> > > data obviously.
> >
> > As a clinician, I dread the day that any patient walks in with a
> > complete hospital record, electronically or otherwise. I then have
> > hundreds of pages or gigabytes of data - an immense haystack from
> > which
> > I must extract a few needles of relevant clinical information. If I
> > fail to do so, I am still at risk legally for this; I have a nightmare
> > of some lawyer who has pored over this mass at US$200/hr trying to
> > extract liability bomblets which he then may lob at me in front of a
> > jury.
> >
> > No, let me as a clinician list the items I know that I need to
> > receive,
> > and I guarantee you that, images and all, I can make do with a CD-R,
> > and
> > with compressed text, a 1.44MB floppy.
> >
> > Your sweaty friend,
> >
> > Dan Johnson md
> >
> >
>
