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实现麻醉记录的自动化记录并改善其呈现方式。

Automating the recording and improving the presentation of the anesthesia record.

作者信息

Ream A K

机构信息

Department of Anesthesia, Stanford University, CA 94305-5117.

出版信息

J Clin Monit. 1989 Oct;5(4):270-83. doi: 10.1007/BF01618260.

Abstract

Although anesthesia records have been kept for over a hundred years, there is still discussion of their value and content. Two uses of the record are widely accepted: (1) review after the anesthetic event (as in medicolegal disputes), and (2) support of patient care during the delivery of an anesthetic. Although the anesthetic record is mandatory in much of the world, there is not a single standard for its format. Automating the generation and presentation of the record will enhance its value and help develop a consensus as to content. Merely automating the steps used to produce the manually generated record does not realize the full benefit of automation. For maximum benefit, the primary goal of automation should be to support the uses of the record. Specific techniques that are discussed include increasing time resolution, optimizing the type and location of input and display equipment, and tailoring the human interface. Particular attention is paid to the issue of how much detail is acceptable in the record, how to use visual cues to present detail properly, how to exclude extraneous detail, and how to avoid misleading presentations (erroneous interpretation of the data). Specific elements discussed include line width, the use of color, presentation of gradients, statistical summaries, contexts for reporting data, graphical techniques for increasing data content, and pictorial presentations. Current records are more often confusing because presented information is inconsistently displayed or irrelevant than because too much information is offered, and automation can ameliorate this problem.

摘要

尽管麻醉记录已经保存了一百多年,但关于其价值和内容仍存在争议。麻醉记录的两种用途已被广泛认可:(1)麻醉事件发生后进行回顾(如在医疗法律纠纷中),以及(2)在麻醉实施过程中为患者护理提供支持。尽管在世界上许多地方麻醉记录是强制性的,但其格式并没有单一的标准。记录生成和呈现的自动化将提高其价值,并有助于就内容达成共识。仅仅对人工生成记录所使用的步骤进行自动化并不能充分实现自动化的益处。为了获得最大益处,自动化的主要目标应该是支持记录的用途。所讨论的具体技术包括提高时间分辨率、优化输入和显示设备的类型及位置,以及定制人机界面。特别关注的问题包括记录中可接受的详细程度、如何使用视觉线索正确呈现细节、如何排除无关细节以及如何避免误导性呈现(对数据的错误解读)。所讨论的具体元素包括线条宽度、颜色的使用、梯度的呈现、统计摘要、数据报告的背景、增加数据内容的图形技术以及图片展示。当前的记录往往更令人困惑,原因是所呈现的信息显示不一致或不相关,而不是提供的信息过多,自动化可以改善这个问题。

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