Gravenstein J S
Department of Anesthesiology, College of Medicine, University of Florida, Hillis Miller Health Center, Gainesville 32610.
J Clin Monit. 1989 Oct;5(4):256-65. doi: 10.1007/BF01618258.
The typical, handwritten anesthesia record of the 1980s does not satisfy its many users. The document is used for clinical care by the anesthetist, nurses, physicians, and technicians in postanesthesia, intensive, and postoperative surgical care units; for historical information by the billing officer, the statistician, and the anesthetist in preparation for a future anesthetic; and for the review of the quality of care by clinical peers and lawyers. For all of these users the typical record contains some to much unnecessary information and lacks some to much needed information. Electronic capture, storage, retrieval, and formatting of data can generate electronic displays or paper records tailored to answer the needs of specific users. The anesthetist in particular will benefit from a well-designed system that takes the place of the traditional handwritten anesthesia record.
20世纪80年代典型的手写麻醉记录无法满足众多使用者的需求。该文件被麻醉师、护士、医生以及术后麻醉、重症监护和术后外科护理单元的技术人员用于临床护理；被计费人员、统计人员以及麻醉师用于获取历史信息，为未来的麻醉做准备；还被临床同行和律师用于审查护理质量。对于所有这些使用者而言，典型记录包含了一些到大量不必要的信息，同时又缺少一些到大量所需的信息。数据的电子采集、存储、检索和格式化能够生成电子显示屏或纸质记录，以满足特定使用者的需求。特别是麻醉师将从一个精心设计的系统中受益，该系统可以取代传统的手写麻醉记录。
