DeLeo J M, Pucino F, Calis K A, Crawford K W, Dorworth T, Gallelli J F
Division of Computer Research and Technology, National Institutes of Health, Bethesda, MD 20892.
Am J Hosp Pharm. 1993 Nov;50(11):2348-52.
A portable, patient-interactive computerized system for obtaining medication histories is described. A comprehensive interview script modeling pharmacist-conducted medication-history interviews was written in lay language. The script contains sections on demographics, current medical conditions, medication regimen, medication compliance, symptoms, allergy history, dietary history, psychosocial history, and occupational and environmental exposure; it also asks the patient to evaluate the system. Some of the information requested is often not obtained by physicians during the history and physical examination. A program that conducts the interview by processing a computerized version of the script was developed with Microsoft QuickBASIC. The program was designed to be run on a personal computer microprocessor so that an interview can be conducted virtually anywhere by using a desktop or laptop computer. Summary reports suitable for inclusion in the medical record are generated after each interview. Patients using the system took an average of 40 minutes to complete an interview. They entered data easily and accurately, and they gave the system a high overall rating. The medication-history interviewing system described produces useful, comprehensive, and consistent reports and requires about the same amount of time to conduct an interview as a human interviewer.
本文描述了一种用于获取用药史的便携式、患者交互式计算机系统。我们用通俗易懂的语言编写了一个全面的访谈脚本,该脚本模仿药剂师进行的用药史访谈。该脚本包含人口统计学、当前医疗状况、用药方案、用药依从性、症状、过敏史、饮食史、社会心理史以及职业和环境暴露等部分;它还要求患者对该系统进行评估。在病史和体格检查过程中,医生通常不会获取某些所要求的信息。我们使用Microsoft QuickBASIC开发了一个程序,该程序通过处理脚本的计算机化版本来进行访谈。该程序设计为在个人计算机微处理器上运行,以便可以使用台式机或笔记本电脑在几乎任何地方进行访谈。每次访谈后都会生成适合纳入病历的总结报告。使用该系统的患者平均花费40分钟完成一次访谈。他们能够轻松、准确地输入数据,并且对该系统给予了很高的总体评价。所描述的用药史访谈系统能生成有用、全面且一致的报告,并且进行一次访谈所需的时间与人工访谈者大致相同。