Campbell J R, Stoupa R, Warren J J
University of Nebraska Medical Center, Omaha.
Proc Annu Symp Comput Appl Med Care. 1991:659-63.
In order to effectively organize the use of nursing time during clinic check-in, we designed a forward chaining rule based program for nursing history taking, problem tracking, and documentation. The program consists of a medical logic module trigger engine which identifies relevant rules for nursing history, an interactive question manager for nursing history taking, and a rule generation shell implemented within a specially designed Medical Query Language (MQL) shcema. At clinic check-in, the engine refreshes the rule set for the patient from interaction with the computerized medical record. The interaction driver assists the nurse with tracking of elapsed time, and allows him/her to pursue questions, record data, and create or complete nursing interventions. Nursing question sets and interventions are maintained longitudinally to assure continuity of care. Nursing problems are created on the problem list within the computerized record as the rule system identifies their existence.
为了在门诊登记期间有效安排护理时间的使用，我们设计了一个基于前向链接规则的程序，用于护理病史采集、问题跟踪和文档记录。该程序包括一个医学逻辑模块触发引擎，用于识别护理病史的相关规则；一个用于护理病史采集的交互式问题管理器；以及一个在专门设计的医学查询语言（MQL）模式中实现的规则生成外壳。在门诊登记时，该引擎通过与电子病历的交互为患者刷新规则集。交互驱动程序协助护士跟踪已过去的时间，并允许其追问问题、记录数据以及创建或完成护理干预措施。护理问题集和干预措施会纵向维护，以确保护理的连续性。随着规则系统识别出护理问题的存在，这些问题会在电子记录中的问题列表上创建。
