Escolar Castellón F, Escolar Castellón J D, Sampériz Legarre A L, Alonso Martínez J L, Rubio Obanos M T, Martínez-Berganza Asensio M T
Servicio de Medicina Interna, Hospital Reina Sofía, Tudela, Navarra.
Med Clin (Barc). 1992 May 30;99(1):17-20.
The following objectives were studied in the implementation of computerization in the registration of clinical histories: gather all the information obtainable from the patient, be able to up-date the information once introduced, use of the information by health care personnel, automatic carrying out of all routine reports, elaboration of hospital indexes, follow the conventional model of clinical history as much as possible and reasonable price.
The study was carried out in a 40-bed department of internal medicine in a county hospital. A mixed system of partial coding was used combined with free texts, the latter being with no limit of space. The clinical histories were structured in 9 groups which covered from personal data to complementary explorations. A personal computer compatible "AT" was employed. The program was designed and analyzed by internal medicine doctors using CLIPPER and language "C".
The thousand one hundred histories were opened with the space occupied in the disc being of 7 Megabytes. Following the premise of: "write all data only once", the obtaining of all type of documents, indexes and listed was automatized facilitating the knowledge of the working of the department directly. Adaptation by medical personnel was good.
The model presented achieved the previously mentioned aims of information gathering and up-dating, use of the information by hospital personnel, automatization of routine reports and indexes, the following of conventional models and economic feasibility. Computerization should not be imposed, must not represent more work and advantages should be obtained by its use.
在临床病历登记实施计算机化过程中研究了以下目标：收集从患者处可获得的所有信息，信息录入后能够更新，医护人员对信息的使用，自动生成所有常规报告，编制医院指标，尽可能遵循传统病历模式以及合理的价格。
该研究在一家县医院的一个拥有40张床位的内科进行。采用了部分编码与自由文本相结合的混合系统，自由文本无空间限制。临床病历分为9组，涵盖从个人资料到辅助检查。使用了一台兼容个人计算机“AT”。该程序由内科医生使用CLIPPER和“C”语言设计和分析。
录入了1100份病历，磁盘占用空间为7兆字节。遵循“所有数据只写一次”的前提，各类文件、指标和列表的获取实现了自动化，便于直接了解科室的工作情况。医护人员的适应性良好。
所呈现的模式实现了上述信息收集与更新、医院人员对信息的使用、常规报告和指标的自动化、遵循传统模式以及经济可行性等目标。计算机化不应被强制推行，绝不能带来更多工作负担，且应通过使用获得优势。
