Lowe W W, Ciszek T A, Gallaher K J
Cape Fear Valley Medical Center, Fayetteville, NC 28302-2000.
Pediatrics. 1992 Jan;89(1):62-6.
A neonatal intensive care unit patient data system, NeoData, which was developed using microcomputers connected by a local area network, is described. The system allows for real-time generation of daily progress notes, as well as admission and discharge summaries. It includes two databases: one for daily patient data and one for admission/discharge summary data. Both sets of data are easily accessible for later analysis and report generation. The daily patient data are entered directly into a computer by the neonatal intensive care unit medical and nurse practitioner staff; a progress note is printed immediately thereafter for inclusion in the patient's chart. Data from the previous day are selectively carried forward into the current day's note, minimizing data entry. Several benefits are derived from this progress note system, including legibility, tracking of laboratory and other data, tracking of management plans and procedures due at a later date, and significant time savings. The system has proved to be easy to learn, and the neonatal intensive care unit staff have found it to contribute to the efficient delivery of patient care.
本文介绍了一个新生儿重症监护病房患者数据系统NeoData，该系统是利用通过局域网连接的微型计算机开发的。该系统允许实时生成每日病程记录以及入院和出院总结。它包括两个数据库：一个用于每日患者数据，另一个用于入院/出院总结数据。这两组数据都便于日后进行分析和生成报告。新生儿重症监护病房的医护人员将每日患者数据直接输入计算机；此后立即打印一份病程记录以纳入患者病历。前一天的数据会有选择地结转至当天的记录中，从而最大限度地减少数据录入。这个病程记录系统带来了诸多益处，包括字迹清晰、对实验室及其他数据的跟踪、对后续到期的管理计划和程序的跟踪，以及显著节省时间。事实证明，该系统易于学习，新生儿重症监护病房的工作人员发现它有助于高效地提供患者护理。
