病历计算机化：在终末期肾病患者护理中的应用

Computerization of the medical record: use in care of patients with endstage renal disease.

作者信息

Pollak V E

出版信息

Kidney Int. 1983 Oct;24(4):464-73. doi: 10.1038/ki.1983.183.

DOI:10.1038/ki.1983.183

Abstract

An on-line computerized medical record system that has been in use for over 5 years is described. Manual forms are a time-oriented problem and event list, a time-oriented record for renal failure, and records for hemodialysis and peritoneal dialysis. The data are entered directly from the forms into the computer. Individual data can be rearranged for display in predetermined or in previously unanticipated ways. Automatic short- and long-term summaries of data on individual patients are available virtually instantaneously. The system has greatly facilitated patient care and the quality control of patient care.

摘要

本文介绍了一个已经使用了5年多的在线计算机化病历系统。手工表格包括一份按时间顺序排列的问题和事件清单、一份肾衰竭的时间顺序记录以及血液透析和腹膜透析记录。数据直接从表格输入计算机。单个数据可以重新排列，以预定的或之前未预料到的方式显示。几乎可以即时获得单个患者数据的自动短期和长期总结。该系统极大地促进了患者护理以及患者护理的质量控制。