Bonney Wilfred, Christie Sean, Paterson Grace, Thibault-Halman Ginette, Alsulaiman Areej
Division of Neurosurgery, Capital Health, Halifax, Nova Scotia, Canada.
Stud Health Technol Inform. 2013;183:195-200.
The increasing use of synoptic operative reports in clinical settings represents a major milestone in the advancement of health information technology. Synoptic operative report templates enable clinicians to capture and display succinct clinical information in a standardized and logical manner. Synoptic operative report templates also provide the optimum goal of enriching personalized health information of a given patient at the point of care so as to support the exchange of clinical information across the continuum of multiple healthcare providers. However, most of the available synoptic operative report templates in many clinical settings do not incorporate interoperable standards in their design and implementation. This paper proposes a novice template (i.e., eSOR-SCI) that uses interoperable standards for its design and implementation.
临床环境中概要手术报告的使用日益增加，这代表了健康信息技术进步中的一个重要里程碑。概要手术报告模板使临床医生能够以标准化和合乎逻辑的方式获取并展示简洁的临床信息。概要手术报告模板还提供了一个最佳目标，即在护理点丰富特定患者的个性化健康信息，以支持跨多个医疗服务提供者的连续过程中的临床信息交换。然而，许多临床环境中现有的大多数概要手术报告模板在其设计和实施中并未纳入可互操作的标准。本文提出了一种新手模板（即eSOR-SCI），该模板在设计和实施中使用了可互操作的标准。
