The laboratory and patient records.

Investigation of an individual patient consists of three essential processes: first, taking a history; secondly, examining the patient; and thirdly, undertaking a variety of tests such as x-ray examinations , biochemical estimations, and so on. Whereas in the past history taking and clinical examination were the most important processes of diagnosis, ancillary investigations are now assuming a far greater importance. In considering the uses of computers in handling the medical record it is obvious that the ancillary and special investigations lend themselves most readily to computerization, since essentially they consist of numerical or clearly definable information. Even though laboratory information lends itself more easily to computerization, it must be remembered that careful consideration should be given as to what part of the information collected should be stored, and what subsequent value it may have. Thus, in recording information, for example, on haemoglobin measurements in the treatment of a patient with anaemia, it may be wasteful to store in permanent form each haemoglobin measurement that has been made as, otherwise, the computerized medical record may be overwhelmingly filled with laboratory information. In such instances it is only necessary, perhaps, to record the haemo-globin concentration on admission, the lowesthaemo-globin concentration, and the haemoglobin concentration on discharge. The main purposes for which hospital records are used are: first, in medical care; secondly, for administrative and medico-legal purposes; and thirdly, for research which may be prospective or retrospective. Opinions differ as to the value of medical records for any of these purposes. Hospital notes, after all, are mainly designed to provide a record of the patient's condition to be utilized in treatment and management. The main contents of the case record have been summarized as consisting of (1) an identification sheet containing information on date of admission, date of discharge, etc; (2) the initial history and physical examination recorded in narrative form; (3) laboratory data and results of functional tests, eg, pulmonary function studies, electrocardiograms, etc; (4) consultation reports containing judgments and therapeutic recommendations in narrative form; (5) operation reports usually in narrative form; (6) therapeutic instructions ; (7) follow-up clinical observations; (8) special reports prepared by hospital departments which provide selective services, for example, radiotherapy, physiotherapy, etc; (9) a discharge summary which is a final synthesis of the patient's history, examination , course of treatment, and outcome. We are here concerned largely with the laboratory and the medical record. Before one can draw …