Friese St, Olthoff D
Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig.
Anaesthesiol Reanim. 2003;28(5):116-24.
In the field of anaesthesia the demands on the quality and quantity of documentation are increasing constantly. Patient Data Management Systems (PDMS) have proved an effective means of handling the volume of data generated. The main reasons for introducing a PDMS vary greatly, nevertheless, it is possible to formulate general requirements such as those of the "Position Paper of the Study Group on Patient Data Management Systems (PDMS) of the University Departments of Anaesthesiology in Bavaria". Although these requirements are very broad, they provide a good basis for comparing different approaches to computer-assisted documentation in anaesthesiology. The stage currently reached at the Department of Anaesthesiology and Intensive Care Medicine (KAI) of the University of Leipzig is analysed in comparison with the position paper. The COPRA system was established at KAI Leipzig eight years ago. It was developed from an existing version for intensive care medicine. It meets the demands made on it when it was introduced and can be enlarged and adjusted to the special needs of anaesthesiology. One particular requirement was that it should be possible to handle computer-assisted documentation and conventional documentation on paper simultaneously. This requirement is met by making the printed forms and those shown on the VDU practically the same in appearance. The anaesthetist is able to recognize "his" record on the screen. This greatly reduces the time required for familiarization and training. If possible, the orientation and updating of the system should be in the hands of an anaesthetist, since this is the only way to ensure that it remains geared primarily to medical needs. Administrative aspects have to be taken into account, but they should not dominate the system. The anaesthetist managing the system should have some basic training in EDP, or at least take a special interest in it. This ensures that minor enlargements can be carried out easily, as soon as required. Proper, expert evaluation of the compiled data requires both a knowledge of medicine and anaesthesiology and an understanding of how information is presented in an EDP system. Enlargements of the system resulting from increasing documentation obligations and quality assurance can be integrated smoothly. In its current form the system is able to depict all parts of the specialist field with the same user interface. By systematically meeting general requirements and taking the special needs of a hospital into account, it has been possible to create a flexible electronic documentation system covering all areas of the anaesthetist's work.
在麻醉领域，对文档质量和数量的要求在不断提高。患者数据管理系统（PDMS）已被证明是处理所产生数据量的有效手段。引入PDMS的主要原因差异很大，然而，有可能制定一些通用要求，例如巴伐利亚州大学麻醉学系患者数据管理系统（PDMS）研究小组的《立场文件》中的要求。尽管这些要求非常宽泛，但它们为比较麻醉学中计算机辅助文档的不同方法提供了良好基础。与该立场文件相比，分析了莱比锡大学麻醉与重症医学系（KAI）目前所达到的阶段。八年前，莱比锡KAI建立了COPRA系统。它是从现有的重症医学版本发展而来的。它满足了引入时对它的要求，并且可以扩大并根据麻醉学的特殊需求进行调整。一个特殊要求是应该能够同时处理计算机辅助文档和传统纸质文档。通过使打印表格和VDU上显示的表格在外观上基本相同来满足这一要求。麻醉医生能够在屏幕上识别“他的”记录。这大大减少了熟悉和培训所需的时间。如果可能，系统的定向和更新应由麻醉医生负责，因为这是确保它主要仍以医疗需求为导向的唯一方法。必须考虑管理方面，但它们不应主导系统。管理该系统的麻醉医生应接受一些基本的电子数据处理培训，或者至少对其有特别兴趣。这确保了一旦需要，就可以轻松进行小的扩充。对汇编数据进行恰当、专业的评估既需要医学和麻醉学知识，也需要了解电子数据处理系统中信息的呈现方式。由于文档义务增加和质量保证而导致的系统扩充可以顺利整合。以其当前形式，该系统能够通过相同的用户界面描绘该专业领域的所有部分。通过系统地满足通用要求并考虑医院的特殊需求，有可能创建一个涵盖麻醉医生工作所有领域的灵活电子文档系统。
