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[产科临床文档记录以及参照结构改革法收集相关数据。72家诊所的调查结果]

[Clinical documentation in obstetrics and collection of relevant data with reference to the structural reform law. Results of a survey of 72 clinics].

作者信息

Butterwegge M, Pluta M

机构信息

Frauenklinik der Städtischen Kliniken Osnabrück.

出版信息

Geburtshilfe Frauenheilkd. 1993 Nov;53(11):783-7. doi: 10.1055/s-2007-1023727.

Abstract

This study was conducted on the spread and usage of computer-aided software programme (GDS) in 72 obstetric departments. Standardised questionnaires were sent to universities and hospitals to ask for information on registered perinatal data. The record with the hand-written delivery book cannot record all data needed for quality protection as the PC is able to list. 89% of the obstetricians evaluate their clinical data regularly by statistical survey and classification. By analysing the general trend they can critically assess their actual obstetrical management. The PC is established in 83%, functions without technical problems in 92% and is optimal in the sequence of operation in 57% of all departments questioned. Overtime hours for the staff could be reduced in 11%, if a computer was used, and in 13% the nurses could take more care of mother and child because of less official red tape. Independent of the size of the department and the data processing knowledge of the staff, the software programme runs efficiently. The comprehensive basis data documentation with all perinatal and neonatal data is used to its full extent in 100% of the cases and documents the clinical effectivity. With regard to the standardised hospital quality control process by the modified requirements in the public health legislation, the directors of the hospital departments are able to assess the quality control and show economic independence.

摘要

本研究针对计算机辅助软件程序(GDS)在72个产科部门的推广及使用情况展开。向各大学和医院发放了标准化问卷,以获取围产期注册数据的相关信息。手写分娩记录册无法记录计算机所能列出的所有质量保障所需数据。89%的产科医生通过统计调查和分类定期评估其临床数据。通过分析总体趋势,他们能够批判性地评估自身实际的产科管理情况。在所调查的所有部门中,83%配备了计算机,92%的计算机运行无技术问题,57%的计算机操作流程最佳。若使用计算机,11%的员工加班时间可减少,13%的护士因文书工作减少,能够更多地照顾母婴。无论科室规模及员工的数据处理知识水平如何,该软件程序均能高效运行。所有围产期和新生儿数据的全面基础数据文档在100%的情况下都得到了充分利用,并记录了临床有效性。根据公共卫生立法修订要求的标准化医院质量控制流程,医院科室主任能够评估质量控制并展现经济独立性。

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