Holbrook J
Emergency Department, Mercy Hospital, Springfield, Massachusetts 01102-9012.
Ann Emerg Med. 1990 Feb;19(2):139-44. doi: 10.1016/s0196-0644(05)81798-6.
The text of 15,009 emergency department medical records was reviewed with the use of a computer program that detected the presence or absence of key words and phrases. The search focused on "trigger diagnoses," that is, any diagnoses associated with an above-average risk for an undetected but more serious condition. Included were the trigger diagnoses from the five high-risk areas of extremity laceration, epiglottitis, abdominal pain, meningitis, and myocardial infarction. The three kinds of medical records that were compared were handwritten records, records dictated and transcribed, and records created by a voice-activated word processor. From a risk management perspective, inclusion of critical pertinent positives and negatives was taken as an index of quality from a risk management perspective, and records created by a voice-activated word processor using real-time risk management prompts were superior to handwritten and dictated records. The computer holds promise as a vehicle to reduce the cost and frequency of malpractice risk in the ED and as a teaching tool to improve the quality of care.
利用一个能检测关键词和短语是否存在的计算机程序，对15009份急诊科医疗记录的文本进行了审查。搜索重点是“触发诊断”，即与未被发现但更严重病情的高于平均风险相关的任何诊断。其中包括来自肢体撕裂伤、会厌炎、腹痛、脑膜炎和心肌梗死这五个高风险领域的触发诊断。所比较的三种医疗记录分别是手写记录、听写和转录记录以及由语音激活文字处理器创建的记录。从风险管理的角度来看，纳入关键的相关阳性和阴性信息被视为风险管理质量的一个指标，并且使用实时风险管理提示的语音激活文字处理器创建的记录优于手写和听写记录。计算机有望作为一种手段，降低急诊科医疗事故风险的成本和发生频率，并作为一种教学工具来提高护理质量。
