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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

The committee report and the commentaries were reviewed by groups other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.

The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education.

See page xv for a listing of the organizations that supported the original and revised reports.

Library of Congress Cataloging-in-Publication Data

Institute of Medicine (U.S.). Committee on Improving the Patient Record.

The computer-based patient record : an essential technology for health care / Committee on Improving the Patient Record, Division of Health Care Services, Institute of Medicine ; Don E. Detmer, Elaine B. Steen, and Richard S. Dick, editors.—Rev. ed.

p. cm

Includes bibliographical references and index.

ISBN 0-309-05532-6

1. Medical records—Data processing. I. Detmer, Don E. II. Steen, Elaine B. III. Dick, Richard S. IV. Title

[DNLM: 1. Medical Records. 2. Medical Records Systems, Computerized—organization & administration. 3. Delivery of Health Care, Integrated—organization & administration. WX 173 159c 1997]

R864.I55 1997



for Library of Congress 97-31030

Copyright 1997 by the National Academy of Sciences

Printed in the United States of America

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logo-type by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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