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一份计算机化的产前记录。

A computerized prenatal record.

作者信息

Studney D R, Adams J B, Gorbach A, Guenthner S, Morgan M M, Barnett G O

出版信息

Obstet Gynecol. 1977 Jul;50(1):82-7.

PMID:301619
Abstract

An entirely computerized ambulatory medical record system is operational in a large health maintenance organization. A unique subsystem was designed for use in prenatal care, in which the provider's completion of a single encounter form at the time of visit meets all the information requirements of care delivery, administration, and quality assurance. Instead of using a conventional paper chart, computer-generated summaries and flow charts are automatically provided for scheduled visits and for use as a hospital preadmission record, significantly reducing the provider effort expended on record keeping. On-line inquiry function is also available using terminals at the ambulatory center and the hospital. The computer data base has been used for quality assurance studies in prenatal care. The system is well accepted by providers, is reliable, and is cost effective.

摘要

一个完全计算机化的门诊病历系统正在一家大型健康维护组织中运行。该系统设计了一个独特的子系统用于产前护理,在这个子系统中,医护人员在就诊时填写一份单次就诊表格,就能满足护理、管理和质量保证方面的所有信息需求。该系统不用传统的纸质病历,而是会自动生成计算机摘要和流程图,用于预约就诊以及作为医院入院前记录,显著减少了医护人员在记录保存上花费的精力。门诊中心和医院的终端还提供在线查询功能。该计算机数据库已用于产前护理的质量保证研究。该系统深受医护人员的认可,可靠且具有成本效益。

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