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在我们有生之年,会看到麻醉领域普遍使用自动记录保存系统吗?自动麻醉记录并不能自动解决记录保存方面的问题。

Will we see automated record keeping systems in common use in anesthesia during our lifetime? The automated anesthetic record will not automatically solve problems in record keeping.

作者信息

Saunders R J

机构信息

Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA 90048.

出版信息

J Clin Monit. 1990 Oct;6(4):334-7. doi: 10.1007/BF02842494.

Abstract

The proponents of automated anesthetic records list the ostensibly logical reasons for them and then claim that automated records will make everything better. The logic goes as follows: (1) It is good to have accurate records because accurate records (a) make clinical decision making more effective and improve patient safety, (b) provide better defense against frivolous lawsuits, and (c) enable more astute medical policy decisions based on improved retrospective case reviews; (2) automatic record-keeping systems will give more nearly accurate records; (3) therefore, quality of care will improve if we acquire automatic record-keeping systems. This logic fails on several counts, which are detailed in this essay. Having said all this, however, I do believe that automated record systems will be implemented and they will be extremely useful, both for the patient and for those who care for the patient. However, we must exercise great care in their design and implementation, lest they wind up doing more harm than good.

摘要

自动麻醉记录的支持者列出了表面上看似合理的理由,然后宣称自动记录会让一切变得更好。其逻辑如下:(1)拥有准确的记录是好事,因为准确的记录(a)能使临床决策更有效,提高患者安全性;(b)能更好地抵御无意义的诉讼;(c)基于改进的回顾性病例审查,能做出更敏锐的医疗政策决策;(2)自动记录系统会提供更接近准确的记录;(3)因此,如果我们采用自动记录系统,医疗质量将会提高。这种逻辑在几个方面存在缺陷,本文将详细阐述。然而,话虽如此,我确实相信自动记录系统将会被实施,而且它们对患者以及照顾患者的人都将极其有用。但是,我们在其设计和实施过程中必须格外谨慎,以免最终造成的危害大于益处。

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