McKegney F P, Schwartz C E, O'Dowd M A, Salamon I, Kennedy R
Department of Psychiatry, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York 10467.
Gen Hosp Psychiatry. 1990 Mar;12(2):71-6. doi: 10.1016/0163-8343(90)90017-7.
Every clinical service must record certain data about its patient care activities. In low-volume services, such as Psychiatric Inpatient Services, with perhaps 20-30 admissions per month, and an average patient stay of 2-4 weeks, a large amount of data on each patient can be obtained during the contact time with the patient. On the other hand, very large-volume psychiatric services, such as Emergency and Consultation-Liaison (C-L) Services, may not need or be able to gather such a large amount of data on every patient seen. This article describes the development of a brief, optically scannable, and computerized minimal data base form for patients seen by a very large division of C-L Psychiatry. The system is feasible and easily auditable for completeness and reliability. This data base has already served many important functions beyond providing an administrative statistical summary of services rendered. It is presented as a model for the development of similarly efficient data collection methods for other high-volume psychiatric services.
每项临床服务都必须记录有关其患者护理活动的某些数据。在诸如精神科住院服务等低流量服务中，每月可能有20 - 30例入院患者，平均住院时间为2 - 4周，在与患者接触期间可以获得大量关于每个患者的数据。另一方面，诸如急诊和会诊联络（C-L）服务等流量非常大的精神科服务，可能不需要或无法收集每个就诊患者的大量数据。本文描述了一种简短的、可光学扫描的、计算机化的最小数据库表格的开发，该表格用于一个非常大的C-L精神科部门就诊的患者。该系统对于完整性和可靠性而言是可行且易于审核的。这个数据库已经发挥了许多重要作用，而不仅仅是提供所提供服务的行政统计摘要。它作为一种模型呈现，用于为其他高流量精神科服务开发类似高效的数据收集方法。
