Rector A L, Nowlan W A, Kay S, Goble C A, Howkins T J
Department of Computer Science, University of Manchester, UK.
Methods Inf Med. 1993 Apr;32(2):109-19.
This paper presents a model for an electronic medical record which satisfies the requirements for a faithful and structured record of patient care set out in a previous paper in this series. The model underlies the PEN & PAD clinical workstation, and it provides for a permanent, completely attributable record of patient care and the process of medical decision making. The model separates the record into two levels: direct observations of the patient and meta-statements about the use of observations in decision making and the clinical dialogue. The model is presented in terms of "descriptions" formulated in the Structured Meta Knowledge (SMK) formalism, but many of its features are more general than the specific implementation. The use of electronic medical records based on the model for decision support and the analysis of aggregated data are discussed along with potential use of the model in distributed information systems.
本文提出了一种电子病历模型，该模型满足本系列前文所述的对患者护理进行忠实且结构化记录的要求。该模型是PEN & PAD临床工作站的基础，它提供了患者护理及医疗决策过程的永久、完全可追溯记录。该模型将记录分为两个层次：对患者的直接观察以及关于在决策和临床对话中观察结果使用情况的元陈述。该模型以结构化元知识（SMK）形式体系中制定的“描述”来呈现，但其许多特性比具体实现更为通用。基于该模型的电子病历在决策支持和汇总数据分析中的应用，以及该模型在分布式信息系统中的潜在应用也进行了讨论。
