Florida Anesthesia Computer and Engineering Team
©
University of Florida, 1996
At the same time as the earliest developments in electronic medical records, the nature of the medical record was being challenged by Larry Weed, who wrote,
"The medical record, it seemed to me, should be not only the physician's laboratory notebook for the recording of observations and investigations, but also his final manuscript. The physician, thereby, would make available to other scientists, other providers of care, and the patients themselves the logic of the conclusions as they emerged from highly organized data about each of the patient's problems. My thesis was that in order to accomplish this, we needed to restructure the medical record. By converting it from a source oriented record (all the data filed according to its source--all the laboratory data together, all the nurse's notes together, etc.--to a problem oriented record, we would automatically have a record not only of what was done, but why it was done. Within such a framework, a fair audit can be accomplished, outcomes can be rigorously interpreted, and a disciplined approach to problem solving can develop in the system of medical care and medical education."
Weed's "problem-based medical record" was a key feature in offering structure to the medical record of physicians, making it more amenable to computerization.
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