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用于介入治疗实践中患者管理的简化HyperCard数据库:4000多例病例的经验。

A simplified HyperCard data base for patient management in an interventional practice: experience with more than 4000 cases.

作者信息

Hahn P F, Lee M J, Gazelle G S, Forman B H, Mueller P R

机构信息

Department of Radiology, Massachusetts General Hospital, Boston 02114.

出版信息

AJR Am J Roentgenol. 1994 Jun;162(6):1443-6. doi: 10.2214/ajr.162.6.8192015.

Abstract

OBJECTIVE

Tracking of interventional radiology procedures is essential for patients' care, follow-up, and quality management, as well as for fellowship training and accreditation. Computer data-base systems that require time-consuming data entry are difficult to use in a practice that performs 1500 abdominal interventional procedures each year while concurrently doing diagnostic imaging. We proposed that a data base updated with data from existing sources and furnishing information used daily in patient management could be maintained by the radiologists it serves.

MATERIALS AND METHODS

We developed a data base to track abdominal interventional radiology cases by using the HyperCard application program running on Macintosh personal computers. For each procedure, one card is entered into the Current Cases stack, which prints a daily log including new patients, those with management issues, and pending biopsy results. Cards for inactive patients are automatically compressed and transferred to a second stack for permanent archive. The latter can be queried to identify individual patients, to list complications, and for research.

RESULTS

In continuous use for 3 years, the system has logged 4322 procedures in 2394 patients. Ninety percent of data entry is by a secretary. The daily log serves as the focus for the case conference at the close of work, when errors are corrected and specific comments entered. Three independent searches for specific types of procedures have failed to identify excluded cases.

CONCLUSION

Easy data entry and error correction, together with useful information provided daily by the data base, are features of the system that promote its consistent use.

摘要

目的

介入放射学操作的跟踪对于患者护理、随访及质量管理至关重要,对住院医师培训及认证也很重要。对于每年进行1500例腹部介入操作同时还开展诊断性成像的科室而言,需要耗时录入数据的计算机数据库系统很难使用。我们提议由所服务的放射科医师维护一个通过现有来源数据更新并提供患者管理日常所用信息的数据库。

材料与方法

我们利用运行在苹果麦金塔个人电脑上的HyperCard应用程序开发了一个用于跟踪腹部介入放射学病例的数据库。对于每例操作,在“当前病例”堆栈中输入一张卡片,该堆栈会打印一份每日日志,包括新患者、有管理问题的患者及待处理的活检结果。非活跃患者的卡片会自动压缩并转移到第二个堆栈进行永久存档。可对后者进行查询以识别个体患者、列出并发症并用于研究。

结果

该系统连续使用3年,已记录了2394例患者的4322例操作。90%的数据录入由一名秘书完成。每日日志是下班前病例讨论会的焦点,会上会纠正错误并录入具体评论。针对特定类型操作的三次独立检索均未发现漏记病例。

结论

该系统具备易于数据录入和纠错以及数据库每日提供有用信息的特点,这些特点促使其得到持续使用。

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