Computerized medical record in a private neurotology practice

Objective: To develop a computerized medical record for a private neurotology practice using a relational database with templates. Background: Computers have been used in the medicine many years for billing, scheduling appointments, and word processing. Neurotology represents a relatively narrow field of medicine, which is particularly suited to a computerized record. A computerized medical record should allow for better data storage and retrieval as well as better documentation of the patient care given. Methods: Using a commercially available, record-keeping software in a local area computer network, templates were developed for several common neurotologic problems. A template for a neurotologic examination was also developed. These were adapted from templates developed by a group otolaryngology practice in a neighboring city. Data entry templates for vestibular and audiologic tests were also developed. Implementation of the computerized record was accomplished in phases, allowing elimination of the paper record. Results: A fully computerized medical record has bren developed and maintained in a private neurotology practice over the past year. Patient response to the computerized record system has been favorable. Office personnel have adapted well to a paperless record, and referring physicians have welcomed the documents generated by the computer. Conclusion: Computerizing the medical records of a neurotology practice is possible and allows for improved documentation, ongoing assessment of treatment results, and improved efficiency among office staff.