Heim K, Heis W, Dapunt O
Universitätsklinik für Frauenheilkunde Innsbruck.
Geburtshilfe Frauenheilkd. 1993 Oct;53(10):667-76. doi: 10.1055/s-2007-1023606.
Update computer technology is an increasingly useful tool in medicine for more accurate documentation, avoidance of multiple documentation, improvement of service performance, quicker and easier data processing and evaluation and hence quality assurance. We developed an obstetric data recording programme for an IBM compatible personal computer according to the MS-DOS command programme. A laser printer with dual paper feed is available. The relational database system Clipper is used for programming. The programme comprises at present 179 data fields and is subdivided on the input side into: data on anamnesis and partus, course of puerperium, infant data. This gives the print-outs: birth protocol, adhesive labels for the temperature curves of the mother and of the infant, respectively, birth record book and mother-infant health passport, furthermore, list print-outs: infant record book, transferred/decreased infants, birth lists relating to midwives, and, in addition, physician's report on the mother and the child, and finally, automated monthly and annual statistics. From August 1990 to July 1992, all events were stored by the computer, so that a total of 5,572 data items have been recorded to date. The primary scope of recording was 98.4% already in the first year of full operation of the database. Computer feed-in was affected directly after each data item became available. Application is fully integrated into normal clinical everyday work. To ensure best possible motivation and acceptance, special attention was paid to user friendliness and immediate print-outs whenever required. Attention was also given to the inclusion of infant follow-up data. The computer programme has been accepted for daily operation, and the necessary data quality has been attained by means of proper choice of the appropriate user groups and manifold measures to ensure integration, safe working, continual servicing and creation of suitable working and data feed conditions.
更新的计算机技术在医学领域正日益成为一种有用的工具,可实现更准确的记录、避免重复记录、提高服务绩效、实现更快更便捷的数据处理与评估,从而确保质量。我们根据MS-DOS命令程序为IBM兼容个人计算机开发了一个产科数据记录程序。有一台具备双进纸功能的激光打印机。使用关系数据库系统Clipper进行编程。该程序目前包含179个数据字段,在输入方面细分为:病史与分娩数据、产褥期过程、婴儿数据。这可生成打印输出:出生记录、分别用于母亲和婴儿体温曲线的不干胶标签、出生记录簿和母婴健康护照,此外还有列表打印输出:婴儿记录簿、转诊/减少的婴儿、助产士相关的出生列表,另外还有医生关于母亲和孩子的报告,最后是自动生成的月度和年度统计数据。从1990年8月到1992年7月,所有事件均由计算机存储,截至目前已记录了总共5572个数据项。在数据库全面运行的第一年,记录的主要范围就已达到98.4%。每个数据项可用后立即直接输入计算机。该应用已完全融入正常的临床日常工作。为确保尽可能高的积极性和接受度,特别注重用户友好性以及在需要时立即打印输出。还关注了纳入婴儿随访数据。该计算机程序已被接受用于日常操作,通过适当选择合适的用户群体以及采取多种措施来确保整合、安全工作、持续维护并创造合适的工作和数据输入条件,已达到了必要的数据质量。