Obladen M, Wagner H, Wille L
Monatsschr Kinderheilkd (1902). 1975 Oct;123(10):700-4.
For the documentation of the neonatal status we use computer-adapted optic mark reader forms since 1972. All important symptoms and signs are scheduled on two sheets and are assigned by pencil marking. The forms can be read automatically and are suitable for data processing. A copy remains in the patients clinical file and can be used like a conventionally written status. The mark reader forms improved singificantly our knowledge about the newborn's status. The problems of introducing the new documentation into the hospital routine are reported.
自1972年以来,我们使用计算机适配的光学标记阅读表格记录新生儿状况。所有重要症状和体征都列在两张表格上,通过铅笔标记进行记录。这些表格可以自动读取,适用于数据处理。一份副本保存在患者的临床档案中,可像传统书写的状况记录一样使用。标记阅读表格显著提高了我们对新生儿状况的了解。报告了将新的记录方式引入医院日常工作中的问题。