Michael P A
HIS Clinical Systems Research, Rex Hospital, Raleigh, NC 27607.
Proc Annu Symp Comput Appl Med Care. 1992:327-31.
Physicians rely on the ready availability of clinical data such as laboratory results and procedure reports for the delivery of quality patient care. Such data may be obtained through telephone calls, printed reports or results review programs provided by hospital information systems, but the process is often time-consuming and laborious. To facilitate rapid access to critical patient data, an online M.D. Rounds Report program, ROUNDS, was developed as an adjunct to the HELP System at Rex Hospital. Qualified users may automatically obtain information on allergies and current medications, laboratory results, radiology reports and therapist notes for a list of patients without having to make additional menu or submenu selections. A detailed description of the M.D. Rounds Report program, along with a review of implementation objectives, physician evaluation, usage statistics, and the impact on future physician subsystem development, will be presented.
医生依靠实验室结果和检查报告等临床数据的随时可得性来提供高质量的患者护理。此类数据可通过电话、打印报告或医院信息系统提供的结果审查程序获取,但这个过程往往既耗时又费力。为便于快速获取关键的患者数据,一个在线医学查房报告程序ROUNDS被开发出来,作为雷克斯医院HELP系统的辅助工具。合格用户无需进行额外的菜单或子菜单选择,就能自动获取一系列患者的过敏和当前用药信息、实验室结果、放射学报告以及治疗师记录。本文将详细介绍医学查房报告程序,并对实施目标、医生评估、使用统计数据以及对未来医生子系统发展的影响进行综述。