Friesdorf W, Schwilk B
Department of Anesthesiology, Ulm University Clinic, Germany.
J Clin Monit. 1992 Oct;8(4):308-14. doi: 10.1007/BF01617913.
Patient-related data management (PDM) has become an increasingly important and time-consuming task in intensive care medicine. Currently, all data are usually collected in a poorly structured patient chart consisting of forms and pictures, with about 400 manual entries a day. To handle this amount of data, we have designed a three-level patient system: level 1, summarizing the whole patient; level 2, summarizing one organ system or one isolated problem; and level 3, variables describing morphology and function of organ systems. PDM must be adapted to different clinical situations. We observed three different scenarios: (1) Exploratory PDM, where the clinician learns about the patient and builds up an individual patient model in his or her mind. (2) Operational PDM, where in routine care clinicians are part of a feedback control system, in which they use the patient-related model. (3) Summary PDM, where a clinician summarizes all the information gathered during a period when he or she was responsible for the patient. Computing tools based on clinical thinking and adapted to different situations can ensure accurate, clear, and concise patient care communication among the members of the intensive care staff.
患者相关数据管理（PDM）在重症医学中已成为一项日益重要且耗时的任务。目前，所有数据通常收集在一个结构不佳的患者病历中，病历由表格和图片组成，每天约有400条手动录入信息。为处理如此大量的数据，我们设计了一个三级患者系统：一级，总结患者整体情况；二级，总结一个器官系统或一个单独问题；三级，描述器官系统形态和功能的变量。患者相关数据管理必须适应不同的临床情况。我们观察到三种不同场景：（1）探索性患者相关数据管理，临床医生在此过程中了解患者并在其脑海中建立个体患者模型。（2）操作性患者相关数据管理，在常规护理中，临床医生是反馈控制系统的一部分，他们在该系统中使用患者相关模型。（3）总结性患者相关数据管理，临床医生在此过程中总结其负责患者期间收集的所有信息。基于临床思维并适应不同情况的计算工具可确保重症监护人员之间进行准确、清晰和简洁的患者护理沟通。
