Computer-held clinical record system. II. Assessment.

A real-time medical recording system installed in two general medical wards has proved to be unacceptable to many of the ward staff. Reasons for this include operational problems, such as the impossibility of providing a 24-hour service, and conceptual problems, such as the difficulty of adapting the method for recording case histories. It is suggested that an outpatient department might have been a better site for this trial, and that deliberate instruction in medical recording should be given to students as a prerequisite to successful computer record keeping.