A MULTI-STRATEGY APPROACH FOR MEDICAL RECORDS OF SPECIALISTS

Despite a number of well recognized shortcomings of paper medical reco rds, the use of a Computer Patient Record (CPR) is not widespread amon g specialists. The complexity of specialized care combined with the di versity of their domains of expertise, make it a challenge to design a CPR that satisfies the needs of a specialist. Ideally, CPRs are tailo red to the specific tasks of each user, and yet general enough to perm it exchange and sharing of information. The basic philosophy behind ou r CPR is a 'mother' record, which is extended with specialized sub-rec ords. Two different types of subrecords are discussed: one to accommod ate standardized data entry in the context of a specialty or research protocol, and another for structured recording of accidental findings outside one's own domain of expertise. The CPR supports the entry of f ree text and does not impose structured data entry on the physician, b ut stimulates him to do so by confronting him with the benefits of a s tructured CPR.