Benoit R G, Cushing B M, Teitelbaum S D, van Wijngaarden M H, Canfield K
National Study Center for Trauma and Emergency Medical Systems, Maryland Institute for Emergency Medical Services Systems, University of Maryland, Baltimore 21201.
Proc Annu Symp Comput Appl Med Care. 1992:787-8.
Injury data in the paper medical record are often inaccurate or lack adequate specificity to evaluate trauma patient care. To improve the quality of recorded injury data, we are testing a graphical, anatomic-based interface for quick collection of detailed injury information directly from the trauma physician. Navigation and data collection throughout the interface are facilitated by anatomic illustrations, menus, lists, and "dialog boxes". Using a "point and click" method, the user selects a specific anatomic structure (i.e., the spleen) from drawings. Detailed injury information, specific to the selected structure, is then collected from the user in an "intelligent" modal dialog box. The software uses SNOMED III nomenclature to create and store ICD, AIS, and trauma registry codes for each injury. Users can review and print abbreviated and detailed injury information for each patient. This demonstration will walk viewers through the injury collection and review process for injuries to the abdomen. We plan to evaluate the interface for accuracy, speed, user satisfaction and resources expended by comparing it with current methods of data collection and injury coding at our level I trauma facility.
纸质病历中的损伤数据往往不准确或缺乏足够的特异性来评估创伤患者的护理情况。为了提高记录的损伤数据质量，我们正在测试一种基于图形解剖学的界面，以便直接从创伤医生那里快速收集详细的损伤信息。整个界面的导航和数据收集通过解剖学插图、菜单、列表和“对话框”来实现。用户采用“点击”方法从绘图中选择特定的解剖结构（即脾脏）。然后，在一个“智能”模态对话框中从用户那里收集所选结构特有的详细损伤信息。该软件使用SNOMED III术语为每种损伤创建并存储ICD、AIS和创伤登记代码。用户可以查看并打印每位患者的简略和详细损伤信息。本次演示将向观众展示腹部损伤的损伤收集和审查过程。我们计划通过将该界面与我们一级创伤机构目前的数据收集和损伤编码方法进行比较，来评估其准确性、速度、用户满意度以及资源消耗情况。
