[Computerized management of the medical record in cardiac surgery. Experience at Foch Hospital].

Between 1979 and 1983, about 2 000 case reports of patients undergoing cardiac surgery were computerised. The availability of the centralised computer facilities of Hôpital Foch made this experiment possible. The computerised case notes were divided into several chapters in which a certain amount of data was compulsive and provision was made for the addition of further information. The data was introduced in the form of a numerical code out of a possible choice of 700 contained in a dictionary. A terminal located in the department was used to introduce the information or to consult a given case file directly. Statistical analysis of the cases was performed using APL language, the basis of which must be known in order to continue interrogation, the reply being almost immediate. Several examples of the use of the system are given: number of patients, average duration of surgery, characteristics of the ten oldest patients. Other studies include the use of double entry tables to determine the relationship between two variables such as the variation of cardiothoracic index and the degree of postoperative bleeding. Each case takes about 20 minutes to be coded; the number of cases not entered has decreased greatly year by year. The differences in language used in comparison with already existing systems are: the use of syntax, the possibility of dating events, an "open" dictionary. The main drawbacks of the system are: forgetting to code certain data and restrictions of interrogation (easier for fixed than for facultative data). The overall results have been clearly positive.(ABSTRACT TRUNCATED AT 250 WORDS)