COMPUTERIZED MEDICAL RECORDS

Computerized medical records serve multiple functions. If a database program can be used for computerizing medical records a thorough and sequential record in a consistent format can be called up for each patient. When a patient comes for a new visit, medication lists are easy to review and revise, progress in pain, psychological state, social circumstances and activity level can be easily determined. Review of systems, documenting time spent in face to face counseling and treatment planning, monthly progress, mental status examination, diagnosis, and treatment planning can all be checked against prior records. This leads to more orderly treatment changes and more stability of treatment as the clinical circumstances warrant.

Using a database allows for much customization and use of pull down menus and check lists. Narrative can be kept brief and to the point. When working in consultation with other physicians the consistency of notes is appreciated. The prerequisites of Medicare can be designed into the notes, so that if audits occur, there is a clear paper and computerized trail of treatment. Finding information in various data fields can be easily achieved and any research requiring information from notes can be quickly accomplished. In some states that allow electronic signature, notes can be sent directly from the computer, without having to sign them. Hard copies are still important because accidents can happen to computer disc drives, CPU's, etc.