Computerized Medical Record — A Tool for Quality Assurance in Primary Health Care

Abstract

The medical record has always been regarded as an important source of information in quality assurance work. The medical history of the patient, examinations, diagnostic tests, the physician’s judgment, and decisions are all documented in the record in a relatively standardized way. In an automated medical record system the information is recorded in a structured form that includes both the use of a predefined vocabulary and the use of free narrative text.