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Medical Database Revisited

Frederic W. Platt, MD
Arch Intern Med. 1991;151(6):1232. doi:10.1001/archinte.1991.00400060140029.
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To the Editor. —  I agree with Sheagren et al1 that our "standard" medical database, at least as found in hospital charts, needs improvement. The authors do a fine service by pointing out how elaborate a good risk factor assessment really is. They also cure the misallocation of alcohol intake and cigarette use to the "social history" section of the record. I presume that they would include such data as frequency of breast self-examination, use of helmets with motorcycles or bicycles, and use of automobile seat belts.Unfortunately, I think that their "new database" is still seriously flawed by omitting "other current active problems" after the present illness. Few of our patients have one single major problem. If the patient appears with a herpes zoster outbreak but also has diabetes mellitus, chronic obstructive lung disease, and hypertension, I see no place for those major active problems until one reaches


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