Safran C, Rury C, Rind D M, Taylor W C
Department of Medicine, Beth Israel Hospital, Boston, MA.
MD Comput. 1991 Sep-Oct;8(5):291-9.
We developed a computer-based outpatient medical record system to facilitate direct physician interaction with the clinical computing system at the Beth Israel Hospital in Boston. During the 2 years since the medical record system was installed, 20 staff physicians, 5 fellows, 64 residents, and 11 nurse practitioners have entered 15,121 active problems and 1996 inactive problems for 3524 patients, as well as 12,651 active medications and 1894 discontinued medications for 3430 patients. Another 20,321 items were entered on health-promotion and disease-prevention screening sheets, and with the help of automatic updating by the computer, an additional 21,897 entries on screening sheets were made for 8686 patients. Clinicians wrote 10.9 +/- 12.8 (mean +/- SD) words per problem when they were working at the computer, as compared with 4.3 +/- 2.5 words per problem when they were writing in the paper medical record. We conclude that physicians will readily enter data directly into a computing system when they are given appropriate tools, and that they consider the computer-based problem list to be a valuable improvement over its paper counterpart. Use of a computer-based medical record system has obvious benefits for data management and patient care.
我们开发了一个基于计算机的门诊病历系统，以促进波士顿贝斯以色列医院的医生与临床计算系统进行直接互动。在安装病历系统后的两年里，20名主治医师、5名研究员、64名住院医师和11名执业护士为3524名患者录入了15121个现存问题和1996个非现存问题，以及为3430名患者录入了12651种现存药物和1894种停用药物。在健康促进和疾病预防筛查表上又录入了20321项内容，并且在计算机自动更新的帮助下，为8686名患者在筛查表上额外录入了21897项内容。临床医生在使用计算机工作时，每个问题平均写10.9±12.8（均值±标准差）个单词，而在纸质病历上书写时，每个问题平均写4.3±2.5个单词。我们得出结论，当为医生提供适当的工具时，他们会很乐意直接将数据录入计算系统，并且他们认为基于计算机的问题列表比纸质的有很大改进。使用基于计算机的病历系统对数据管理和患者护理有明显的好处。
