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Pediatrics and Record-keeping

DAVID SPARLING, MD
Am J Dis Child. 1980;134(3):326. doi:10.1001/archpedi.1980.02130150080024.
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ABSTRACT

Sir.—I appreciated the careful study of the use of ambulatory medical records reported by Margolis and Porter (Journal 132:1115-1116, 1978). Although their observations are clearly presented, I had thought that the responsibility of the pediatrician at any acute ambulatory visit would involve review of the patient's total health status. Identification of chronic health problems and their current condition, review of health problems identified at the last visit or by telephone during the interval, determination of immunization status and currentness of preventive health care, inquiry regarding additional health problems, and identification of the time of the next appropriate ambulatory visit would be included. Furthermore, recurrent health problems are so much the rule in pediatrics that, except in the setting of the occasional emergency room visit, it would seem to me that the time expended in identifying the case with a nonrecurrent problem would outweigh the saving achieved by not pulling

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