手工和计算机化问题导向型病历系统的审核效用。
The utility for audit of manual and computerized problem-oriented medical record systems.
作者信息
Stratmann W C, Goldberg A S, Haugh L D
出版信息
Health Serv Res. 1982 Spring;17(1):5-26.
Objective assessment of the delivery of care requires an unambiguous record of all related events and decisions in the care process. Both the handwritten Problem-Oriented Medical Record (POMR) and its computerized successor, the Problem Oriented Medical Information System (PROMIS) have been designed to facilitate audit of care delivery. In this study, a national sample of physicians was asked to determine which of these two record systems best serves the function of audit. The study involves assessment of a sample of 69 matched pairs of patient records drawn from two different ward settings, one of which used the manual POMR, the other, PROMIS. No difference was perceived between the two records with respect to the reliability of information or the analytical reasoning of providers. Information in PROMIS records was judged to be slightly more thorough. The format of the manual record was judged better on the basis of conciseness, accessibility, and organization of record information.
对医疗服务提供情况进行客观评估需要在护理过程中对所有相关事件和决策进行明确记录。手写的问题导向型医疗记录（POMR）及其计算机化继任者问题导向型医疗信息系统（PROMIS）都是为便于审核医疗服务提供情况而设计的。在本研究中，对全国范围内的医生样本进行了调查，以确定这两种记录系统中哪一种最能满足审核功能。该研究涉及对从两个不同病房环境中抽取的69对匹配患者记录样本进行评估，其中一个病房使用手动POMR，另一个使用PROMIS。在信息可靠性或提供者的分析推理方面，两种记录之间没有差异。PROMIS记录中的信息被认为稍微更全面一些。基于记录信息的简洁性、可获取性和组织性，手动记录的格式被认为更好。
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