Peters R M
Department of Surgery, University of California, San Diego 92103.
J Clin Monit. 1989 Oct;5(4):266-9. doi: 10.1007/BF01618259.
Written records and first-generation hospital information systems do not meet their primary purpose to assist physicians in solving patients' problems. Simply automating the present chart formats is not the answer. An example of the concept needed for charting is the intensive care unit chart. Anesthesiology charts provide little useful information for the continued care of the patient postoperatively. They serve principally as legal archival documents. Automation of the anesthesia record should free the anesthesiologist of the need to search for preoperative information and to manually record most information intraoperatively. Decisions about how much data to archive and how to extract the data pertinent to continuing care are the challenges for physicians. The technologic tools are available for the design and implementation of a software system that focuses on effective communication of the patient's problems throughout the perioperative period as the patient moves from ward to operating room, through the recovery room and intensive care unit, and to the ward and home.
书面记录和第一代医院信息系统无法实现其主要目的,即协助医生解决患者问题。仅仅将当前的病历格式自动化并非解决之道。图表记录所需概念的一个例子是重症监护病房的图表。麻醉科图表对于患者术后的持续护理几乎没有提供有用信息。它们主要用作法律存档文件。麻醉记录的自动化应使麻醉医生无需再搜索术前信息并在术中手动记录大部分信息。对于医生来说,决定存档多少数据以及如何提取与持续护理相关的数据是一大挑战。现在已有技术工具可用于设计和实施一个软件系统,该系统专注于在患者从病房到手术室、经过恢复室和重症监护病房、再到病房和家中的整个围手术期有效传达患者的问题。