Llewelyn D E, Ewins D L, Horn J, Evans T G, McGregor A M
Department of Medicine, King's College School of Medicine and Dentistry, London.
BMJ. 1988 Dec 10;297(6662):1504-6. doi: 10.1136/bmj.297.6662.1504.
A new type of clinical summary, produced by copying standard descriptions of diseases on to a computer screen and editing them to match a patient's findings and diagnoses, was updated and reprinted as the patient's condition changed in the ward or as an outpatient. When this method was used to produce typed medical discharge summaries over a three month period, 73 out of 91 (80%) were sent out within a week after discharge compared with five out of 56 (9%) conventionally typed summaries received in a single general practice. Even completely new computerised summaries are quicker for the secretary to produce than conventional summaries, and the computerised summaries are designed to be scanned rapidly for relevant information. They can also be used to collect data automatically for research, clinical audit, and resource management.
一种新型临床总结报告，通过将疾病的标准描述复制到电脑屏幕上并进行编辑以匹配患者的检查结果和诊断，会随着患者在病房或门诊病情的变化而更新和重印。在三个月的时间里，当使用这种方法生成打印版的医疗出院总结时，91份中有73份（80%）在出院后一周内发出，相比之下，在一家全科诊所收到的56份传统打印总结中，只有5份（9%）在一周内发出。即使是全新的电脑化总结，秘书生成起来也比传统总结更快，而且电脑化总结旨在能快速扫描以获取相关信息。它们还可用于自动收集数据以进行研究、临床审计和资源管理。
