The amount of recorded information from a medical interview by note-taking was compared with that received with no note-taking. The study with 46 medical students suggests that note-taking facilitates recall and that there is a progressive decay of memory recall with the passage of time between the physician-patient interview and the recording of…

A logbook system for recording students' patient-care activities during a clerkship is described. It was designed at Southern Illinois University School of Medicine to provide data for assessing students and for evaluation of the clerkship itself. Student logbooks are collected at the midpoint and end of the clerkship. (MLW)

The process implemented at the Ohio State University College of Medicine systematizes the procedures for managing a greatly increased volume of applications. The historical development, continuing research efforts, and computer support system for the process are discussed. (Editor/LBH)

A logically constructed format for the recording of the patient's personality profile is proposed. The term "personality" is used in a broad sense and refers to data that should be part of the patient's clinical record in any clinical situation and that describe the patient's general vulnerability. (Author/MLW)

A computerized patient record-keeping system in a pediatric residency program revealed limitations in residents' patient experiences and imbalances in their workload and curriculum and has been used by the faculty to correct them. The system uses eight interactive programs in the BASIC language. (MSE)

Documentation has assumed increasing importance as more hospital boards require applicants to produce a listing of their procedural and diagnostic experience when applying for hospital privileges. It is possible that documentation will become an essential component of both graduate training programs and private practice. (MLW)

The effect of the use of guidelines on the care of patients with breast, colon, and non-small-cell lung cancers is reported. Audits of patient records revealed an increase over time in the percentage of recommended cancer care procedures that were complied with. (Author/MLW)

Collecting patient morbidity information in academic ambulatory practice is useful for research, practice management, and evaluation and planning of educational programs. Three methods of morbidity data collection were compared to determine which was most accurate. (Author/MLW)

A system of data recording and retrieval which defines a family practice population of patients is described. The costs of this recording process in nonteaching practices, the use of such data as an educational resource for the training of primary care physicians, and the evaluations of health care delivered are discussed. (Editor/JT)

A project was initiated to determine whether protocols for the management of dysuria would be accepted by clinic house officers and whether these protocols could influence the care given to patients. Positive results were obtained in both areas. Significant improvement in documentation of patient history and diagnostic accuracy were noted. (JMD)

In response to discussion concerning the fate of the medical internship, the authors analyze the patient experiences an intern encountered--finding them to deal exclusively with care of acutely ill persons--and conclude that the traditional internship is unrealistic with respect to the practice of medicine. The importance of record keeping is…

Reports studies of the validity of medical data recorded and computerized at University of Western Ontario family medical centers. In the 59 encounters observed residents recorded an average of 1.51 problems and observers 2.45. Implications for medical education, audit, research, computer systems, and quality of care are discussed. (JT)

Experience with the Computer Stored Ambulatory Record (COSTAR), a computerized medical records system, installed at a large primary care clinic at a university medical center is reported. Use of the system was terminated because clinic revenues could not cover operating costs. (Author/MLW)

Selective enrollment of patients at a model family practice unit provides a full range of medical problems for residents. A computerized, problem-oriented medical record is used to help distribute families with selected chronic diseases equitably. Reallocation of families to new residents in cycles is logically planned and workloads are monitored.…

Advantages and disadvantages discovered during introduction of computerized patient-care recordkeeping at the National Institute of Health's Clinical Center are discussed, including the needs for physicians to change some behaviors and for better records, changes in the relationship between nurse and physician, and adjustment problems in inputting…