Lesser M F
J Am Coll Cardiol. 1986 Oct;8(4):941-8. doi: 10.1016/s0735-1097(86)80439-9.
Major strides in both computer hardware and software with respect to costs, reliability and user friendliness have made computer systems more and more popular for information management. Although the acquisition and maintenance of patient medical records lend themselves extremely well to computerization, there are few, if any, descriptions of successful implementations of computerized medical records in a private clinical practice. This article examines the basic fundamentals of the medical record, compares paper and computerized records and describes a specific computerized office system installed in a private cardiovascular/internal medicine practice with specific emphasis on patient medical records.
在计算机硬件和软件方面,在成本、可靠性和用户友好性上取得的重大进展使得计算机系统在信息管理方面越来越受欢迎。尽管患者病历的获取和维护非常适合计算机化,但在私人临床实践中,关于计算机化病历成功实施的描述却很少(如果有的话)。本文探讨了病历的基本要素,比较了纸质病历和计算机化病历,并描述了一个安装在私人心血管/内科诊所的特定计算机化办公系统,特别强调了患者病历。