Andrews R D, Gardner R M, Metcalf S M, Simmons D
Respir Care. 1985 Aug;30(8):695-707.
A respiratory care computer-charting system was developed and implemented as an addition to our hospital's computerized information system. Medical personnel charted and reviewed respiratory care procedures at nursing station computer terminals instead of using the patient's traditional paper chart. The computer automatically performed billing and provided management as well as clinical information. In an attempt to isolate specific benefits or shortcomings, we evaluated charting systems both before and after computer implementation. Four assessments were made: (1) a survey of therapists' attitudes, (2) an observation of work patterns, (3) an audit of the content of charting, and (4) an analysis of productivity statistics. Computer charting was well accepted by therapists. Charge capture was reduced from a four-step manual process to a single-step computer documentation of the procedure. Computer charting was more complete and informative. Productivity increased 18%, although it remains unclear to what degree the computer was responsible. Computer charting streamlined the process of documentation and allowed more beneficial use of clinical information.
一个呼吸护理计算机图表系统被开发并实施，作为我们医院计算机信息系统的补充。医护人员在护士站的计算机终端上记录和查看呼吸护理程序，而不是使用患者的传统纸质病历。计算机自动执行计费，并提供管理和临床信息。为了找出具体的优点或缺点，我们在计算机实施前后对图表系统进行了评估。进行了四项评估：（1）对治疗师态度的调查，（2）对工作模式的观察，（3）对图表内容的审核，以及（4）对生产率统计数据的分析。计算机图表受到了治疗师的广泛接受。收费获取从一个四步手动过程减少到程序的单步计算机记录。计算机图表更完整且信息更丰富。生产率提高了18%，尽管尚不清楚计算机在多大程度上起到了作用。计算机图表简化了记录过程，并使临床信息得到更有益的利用。
