Data retrieval in the coronary care unit: prospective vs. retrospective.

A standardized system for recording patient care data for medical audit was developed and implemented in six community hospitals' coronary care units. It utilized the principles of predefining the data base and having both nurses and physicians participate. This system was compared with conventional retrospective record abstraction as a source of information for medical audit.

Non-physician development of problem lists from office records.

It has been argued that conversion of office records to the problem-oriented medical record entails a prohibitive cost in money and physician time. This study reports an evaluation of the cost of preparing problem lists from existing ambulatory patient records by non-physician personnel. The problem lists constructed by non-physician personnel were judged by physicians to be accurate, and the cost was much less than that required when physicians reviewed charts and prepared problem lists themselves.