Building and Using an Outcomes Oriented Patient Record in Clinical Practice

Continuous, site-specific outcome assessment can indicate opportunities for improvement and can measure the results of changes in local health care practices. We have built a computer based clinical record which brings a variety of outcome measures to everyday clinical practice. Some of these measurement tools are objective, others subjective. All are practical, validated, and clinically relevant. Serial records in an electronic format generate a database which allows useful definitions of populations and outcomes. After using our model for over 1000 records we exported it successfully from our office to offices of colleagues and to local hospital clinics. In this electronic poster, we discuss the construction of such site specific, outcomes oriented, electronic clinical records.