基于计算机的患者记录：基本数据集方法。
Computer-based patient record: the essential data set approach.
作者信息
Moidu K, Falsone J J, Nair S
机构信息
Beulah Hinds Center for Health Informatics, Section for Pulmonary and Critical Care Medicine, Norwalk Hospital, CT 06856.
出版信息
Proc Annu Symp Comput Appl Med Care. 1994:462-6.
The clamor for data to study the impact of care, to evaluate clinical performance and justify resource utilization is increasing. The data in demand normally should exist in the record of a clinical encounter. Advances in information technology and software techniques have provided us with tools to develop and implement computer-based patient record systems. The issues that constrain development are integral issues of clinical medicine, such as the variability in medical data, specialized practice of medicine, and differing demands of the numerous end-users of a medical record. This paper describes an approach to develop a computer-based patient record. The focus is on identification of the essential data set by infological data modeling and its implementation in a commercially available package for a physician's office.
为研究医疗护理的影响、评估临床绩效并证明资源利用的合理性而对数据的需求日益增加。通常所需的数据应存在于临床诊疗记录中。信息技术和软件技术的进步为我们提供了开发和实施基于计算机的患者记录系统的工具。限制开发的问题是临床医学的固有问题，例如医疗数据的变异性、医学专业实践以及医疗记录众多最终用户的不同需求。本文描述了一种开发基于计算机的患者记录的方法。重点是通过信息学数据建模识别基本数据集，并将其在医生办公室的商用软件包中实现。
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