BMJ volume 295, issue 6591, P184-190 1987 DOI: 10.1136/bmj.295.6591.184 View full text
M J Quaak, R F Westerman, J H van Bemmel

Abstract: AbstractPatient histories were obtained from 99 patients in three different ways: by a computerised patient interview (patient record), by the usual written interview (medical record), and by the transcribed record, which was a computerised version of the medical record. Patient complaints, diagnostic hypotheses, observer and record variations, and patients' and doctors' opinions were analysed for each record, and records were compared with the final diagnosis.About 40% of the data in the patient record were …

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