Nielsen P E, Thomson B A, Jackson R B, Kosman K, Kiley K C
Department of Obstetrics & Gynecology, Madigan Army Medical Center, Tacoma, Washington 98431, USA.
Obstet Gynecol. 2000 Dec;96(6):1003-8. doi: 10.1016/s0029-7844(00)01073-5.
To develop, implement, and evaluate an electronic record that tracks antepartum, intrapartum, and postpartum care.
The Standard Obstetric Record Charting system (STORC) was created by a group of programmers and clinicians who developed screen designs, reports, pick lists, and standard notes, and ensured a flexible, yet standard system. To evaluate data within the system, ORYX (Joint Commission) performance measures were collected retrospectively and compared with STORC data.
The STORC, officially implemented as our complete inpatient and outpatient obstetric record in March 1998, provided seamless integration of antepartum, intrapartum, and postpartum care records, standard forms, and standard and ad hoc reports. Data for customizable case and procedure lists are generated easily. Unplanned and total cesarean deliveries were identified retrospectively in 0% (0 of 18) of charts reviewed for ORYX; however, STORC identified the actual rates of each as 8.3% (23 of 276) and 12.3% (34 of 276), respectively. Other critical ORYX measures not identified by retrospective data collection, but accurately provided by STORC, included rates of third and fourth degree lacerations, postpartum hemorrhage, low and extremely low birth weights, and macrosomia.
After implementation in a large referral center, completeness and accuracy of charting and rapid access to obstetric outcome data were improved. Provider acceptance of the system also was dramatic and improved over time as a result of direct development oversight by obstetric health care providers, local control of system changes, and immediate access to outcome data. (Obstet Gynecol 2000;96:1003-8.)
开发、实施并评估一个跟踪产前、产时及产后护理的电子记录系统。
标准产科记录图表系统（STORC）由一组程序员和临床医生创建，他们设计了屏幕界面、报告、选择列表和标准注释，并确保该系统灵活且标准化。为评估系统内的数据，回顾性收集了（联合委员会的）ORYX绩效指标，并与STORC数据进行比较。
STORC于1998年3月正式作为我们完整的住院和门诊产科记录实施，实现了产前、产时及产后护理记录、标准表格以及标准和临时报告的无缝整合。可轻松生成可定制的病例和手术列表数据。在为ORYX审查的图表中，回顾性发现计划外剖宫产和总剖宫产率均为0%（18例中0例）；然而，STORC确定实际发生率分别为8.3%（276例中23例）和12.3%（276例中34例）。其他未通过回顾性数据收集识别但STORC准确提供的关键ORYX指标包括三度和四度会阴裂伤率、产后出血率、低出生体重和极低出生体重率以及巨大儿发生率。
在一个大型转诊中心实施后，图表记录的完整性和准确性以及对产科结局数据的快速获取得到了改善。由于产科医疗保健提供者的直接开发监督、系统更改的本地控制以及对结局数据的即时访问，随着时间的推移，提供者对该系统的接受度也显著提高且有所改善。（《妇产科学》2000年；96:1003 - 8）
