Peng T C, VanDorsten J P, Dilzer P, Perry C, Ozcan G, Adams K, Dunn L J
Department of Obstetrics and Gynecology, Medical College of Virginia/Virginia Commonwealth University, Richmond.
Proc Annu Symp Comput Appl Med Care. 1991:598-602.
Described in this paper is the implementation and integration of an obstetrical medical record and database into an existing hospital information system. A unique feature of this system was the integration of existing data captured by the established hospital information systems with the newly implemented obstetrical database to form a complete patient data profile. This complete database integrated data from hospital functions such as demographic data obtained at patient registration, outpatient visits and tests, inpatient admission historical data, tests and procedures, newborn data and miscellaneous data required for birth registration. An important second feature was the utilization of physicians and nurses to enter the obstetrical data. This permitted immediate access to patient data from any hospital information system terminal, immediate retrieval for generating reports, and subsequently, ad hoc queries, statistical analysis and the electronic transfer of birth registration data to the State Vital Statistics Registry.
本文描述了将产科病历和数据库实施并集成到现有的医院信息系统中的过程。该系统的一个独特之处在于，将已建立的医院信息系统捕获的现有数据与新实施的产科数据库进行整合，以形成完整的患者数据档案。这个完整的数据库整合了来自医院各项功能的数据，如患者登记时获取的人口统计数据、门诊就诊和检查数据、住院入院历史数据、检查和程序数据、新生儿数据以及出生登记所需的其他杂项数据。第二个重要特点是利用医生和护士录入产科数据。这使得可以从任何医院信息系统终端立即访问患者数据，立即检索以生成报告，随后还可进行临时查询、统计分析以及将出生登记数据电子传输至州生命统计登记处。
