Séné B, Venot A, de Zegher I, Milstein C, Errore S, de Rosis F, Strauch G
Département de Biostatistiques et Informatique Médicale et IRT-ECLIMED, Hôpital Cochin (Université René Descartes-Paris V), France.
Methods Inf Med. 1995 Sep;34(4):310-7.
Currently, there is no widely accepted structured representation of drug prescription. Nevertheless, a structured representation is required for entering and storing drug prescriptions avoiding free text in computerized systems, and for drug prescription reviews. Derived from part of the work of the European OPADE project, we describe an object-oriented model of drug prescription which incorporates important concepts such as the phase and triggering event concepts. This model can be used to record all drug prescriptions, including infusions, in a structured way avoiding free text. The phase concept allows the storage of sequentially ordered dosage regimens for a drug within the same prescription. The prescription triggering event concept allows recording of the administration of a drug conditional to dates, symptoms and clinical signs, medical procedures, and everyday life events. This model has been implemented within the OPADE project; the corresponding aspects of the user interface are presented to show how this model can be used in practice. Even if other new attributes may be added to the described objects, the structure of this model is suitable for general use in software which requires the entry, storage and processing of drug prescriptions.
目前，尚无被广泛接受的药物处方结构化表示形式。然而，在计算机系统中输入和存储药物处方时需要一种结构化表示形式，以避免使用自由文本，同时也用于药物处方审查。源自欧洲OPADE项目的部分工作，我们描述了一种药物处方的面向对象模型，该模型纳入了诸如阶段和触发事件概念等重要概念。此模型可用于以结构化方式记录所有药物处方，包括输液，避免使用自由文本。阶段概念允许在同一处方中存储药物按顺序排列的给药方案。处方触发事件概念允许记录根据日期、症状和体征、医疗程序以及日常生活事件来给药的情况。该模型已在OPADE项目中实现；展示了用户界面的相应方面，以说明该模型在实际中如何使用。即使可能会向所描述的对象添加其他新属性，此模型的结构也适用于需要输入、存储和处理药物处方的软件中的一般用途。
