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病例手册:一种用于跟踪临床诊疗过程的系统。

Casebook: a system for tracking clinical encounters.

作者信息

Kahn J A, Piggins J, Blewett D R, Hassan L, Raila W, Link D, Oliver D E, Barnett G O

机构信息

Laboratory of Computer Science, Massachusetts General Hospital, Boston.

出版信息

Proc Annu Symp Comput Appl Med Care. 1991:718-22.

Abstract

Casebook is a clinically oriented database, written in MUMPS, and designed for recording the clinical encounters of medical students at Harvard Medical School. Its main goals are to 1) increase student use of computer technology, 2) help faculty evaluate the diversity of clinical experiences on their service, 3) provide data to the faculty on the "typical" experience of medical students on their service to aid in the evaluation of the curriculum and, 4) provide report-generation capabilities for the students to improve dialog with their preceptors. Students are able to enter information on "Problems" and "Procedures" selecting from a pop-up menu of medical terms or by entering free text. Casebook is currently in use in the Medicine, OB/GYN, Pediatric and Ambulatory rotations. At sites where the faculty take an active interest in the use of Casebook students perceive it to be valuable and subsequently use it more frequently. It is currently being expanded for use by medical students in their second, third, and fourth years of school.

摘要

病例手册是一个以临床为导向的数据库,用MUMPS编写,旨在记录哈佛医学院医学生的临床诊疗经历。其主要目标是:1)增加学生对计算机技术的使用;2)帮助教师评估其服务中临床经验的多样性;3)向教师提供医学生在其服务中的“典型”经验数据,以协助课程评估;4)为学生提供报告生成功能,以改善与带教老师的交流。学生能够从医学术语弹出菜单中选择或通过输入自由文本,输入有关“问题”和“诊疗程序”的信息。病例手册目前在医学、妇产科、儿科和门诊轮转中使用。在教师积极关注病例手册使用的场所,学生认为它很有价值,随后使用频率更高。目前它正在扩展,供二、三、四年级医学生使用。

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