Bradbury A R
USAF Hospital Altus/SGHF, Altus AFB, OK 73523-5300.
Med Inform (Lond). 1991 Jul-Sep;16(3):279-86. doi: 10.3109/14639239109025302.
The inevitable computerization of medical records may be a boon or a hindrance to the practice of medicine. A comprehensive view of the project is essential for its success. Definite goals for the computerized medical record are stated to this end. An argument is presented for keeping the structure of the medical record separate from any specific requirements of technology. An elegant structure for medical records is proposed, independent of any computer system and requiring a minimum of definitions or special characters. The roles of clinical specialists (such as physicians and nurses), medical records specialists, administrators, accountants, and computer architects (hardware and software) are defined. In particular, the tasks of lexicon and template creation are defined and emphasized as urgent and ongoing challenges for specialty organizations.
医疗记录的计算机化不可避免，这对医疗实践可能是福音，也可能是障碍。对该项目有全面的认识对其成功至关重要。为此，阐述了计算机化医疗记录的明确目标。提出了一种观点，即医疗记录的结构应与任何特定技术要求分开。提出了一种简洁的医疗记录结构，它独立于任何计算机系统，只需最少的定义或特殊字符。明确了临床专家（如医生和护士）、医疗记录专家、管理人员、会计以及计算机架构师（硬件和软件）的角色。特别是，词汇表和模板创建任务被定义，并强调这是专业组织面临的紧迫且持续的挑战。
