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基于计算机的患者记录系统。

Computer-based patient record systems.

作者信息

Chamorro T

机构信息

Cedars Sinai Medical Center, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, USA.

出版信息

Semin Oncol Nurs. 2001 Feb;17(1):24-33. doi: 10.1053/sonu.2001.20416.

Abstract

OBJECTIVES

To provide oncology nurses with an overview of computer-based patient record (CPR) systems, a key infrastructure requirement in information management that is essential to maintaining a scientific basis for health care.

DATA SOURCES

Published articles, research studies, and review articles pertaining to CPR systems.

CONCLUSIONS

Progress in hardware development, software applications, and interfaces combine to bring us multimedia patient record systems. Many obstacles have been overcome as standards have emerged and technologies conform to those standards. However, there has been limited success in implementation of such systems. Early acceptance of structured data and problem-oriented documentation set the framework for charting in the electronic record.

IMPLICATIONS FOR NURSING PRACTICE

Oncology clinicians and cancer patients alike will realize greater efficiencies and increased quality in health care when the CPR is fully implemented.

摘要

目的

为肿瘤专科护士概述基于计算机的患者记录(CPR)系统,这是信息管理中的一项关键基础设施要求,对维持医疗保健的科学基础至关重要。

数据来源

与CPR系统相关的已发表文章、研究及综述文章。

结论

硬件开发、软件应用和接口方面的进展共同带来了多媒体患者记录系统。随着标准的出现以及技术符合这些标准,许多障碍已被克服。然而,此类系统的实施取得的成功有限。对结构化数据和面向问题的文档的早期接受为电子记录中的图表绘制奠定了框架。

对护理实践的启示

当CPR得到充分实施时,肿瘤专科临床医生和癌症患者都将在医疗保健中实现更高的效率和更高的质量。

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