van Ginneken A M, Stam H, Duisterhout J S
Department of Medical Informatics, Erasmus University, Rotterdam, The Netherlands.
Proc Annu Symp Comput Appl Med Care. 1994:496-500.
Especially in the Netherlands, the introduction of computer patient records (CPRs) in primary care has been relatively successful. Specialists usually maintain more extensive records than general practitioners and it has proven to be a great challenge to design a CPR that is useful and practical for specialized care. In this paper, we present the design of a CPR for use by specialists in an out-patient clinic. The philosophy underlying the design is that specialists may keep record in a relatively conventional way, while, at the same time, the system motivates them to add structure to their data. Data can be presented in various views, each suitable for one or more specific tasks. The potential to benefit from these views depends on the degree of structure in the recorded data. Since a CPR has to be faithful and permanent, explicit representation of observations, insights, and evolution of insight is also supported. The CPR system is in a final stage of implementation and will be evaluated in a clinical setting in summer 1994.
特别是在荷兰，初级保健中引入计算机化病人记录（CPR）相对较为成功。专科医生通常比全科医生保存更详尽的记录，事实证明，设计一种对专科护理有用且实用的CPR是一项巨大挑战。在本文中，我们展示了一种供门诊专科医生使用的CPR的设计。该设计的基本理念是，专科医生可以以相对传统的方式保存记录，同时，系统促使他们为自己的数据增添结构。数据可以以各种视图呈现，每个视图适用于一个或多个特定任务。从这些视图中获益的潜力取决于所记录数据的结构化程度。由于CPR必须准确且持久，因此还支持对观察结果、见解及见解演变进行明确表示。CPR系统正处于实施的最后阶段，并将于1994年夏季在临床环境中进行评估。
