MINIRECORD - AID TO CONTINUITY OF CARE

Abstract

A simple, low cost computerized minirecord system (minimal essential record) has been in full operation for 2 yr in the Medical Clinic. The primary objective of the minirecord system is to permit rapid retrieval of current information concerning Medical Clinic patients. The system provides a computer-printed listing of problems and medications in the front of each chart and on-line display of this information at strategically located computer terminals. The information is generated via existing simple systems with minimal additional effort and with the use of any appropriate terminology. Chart review revealed that minirecords were actually present in 92% of the charts and that significant improvement occurred in the recognition on a subsequent visit of clearly defined problems and therapies noted on the initial minirecord. Current modifications should replace the separate minirecord and encounter form (registration and visit note) with a single form that facilitates completion and updating. The rapid availability of this information provides a mechanism for coordinating continuing care in a university hospital system that is otherwise inevitably fragmented and composed of multiple health care providers.