Kennelly B M, Vader C G
Intensive Care Med. 1980;6(1):9-17. doi: 10.1007/BF01683075.
A report form is described which has been designed to cover the likely diagnoses of patients admitted to a cardiac intensive care unit. The information entered can readily be stored for computer retrieval and includes biographical and clinical data, information pertaining to medications, procedures, complications, arrhythmias, and electrocardiographic and serum enzyme values, with special reference to patients with acute myocardial infarction. The data is entered by the medical, nursing and secretarial staff prior to encoding and computer storage. The report from which has evolved from its prototype 7 years ago, is described in the hope that it may be a basis for modification to the needs of other cardiac intensive care units presently without a data retrieval system.
本文描述了一种报告表,其设计目的是涵盖入住心脏重症监护病房患者可能的诊断情况。录入的信息可轻松存储以供计算机检索,包括个人信息和临床数据、与药物、操作、并发症、心律失常以及心电图和血清酶值相关的信息,尤其针对急性心肌梗死患者。这些数据由医疗、护理和秘书人员在编码和计算机存储之前录入。该报告表是在7年前的原型基础上发展而来的,希望它能作为修改的基础,以满足目前没有数据检索系统的其他心脏重症监护病房的需求。