Chessare J B, Torok K E
Department of Pediatrics, Medical College of Ohio, Toledo 43699.
MD Comput. 1993 Jan-Feb;10(1):23-7.
High-quality medical care requires a medical record that is complete, legible, and readily available. Information storage and retrieval are often more difficult in academic group practices than in private offices because of the complexity of the delivery system. We implemented a computerized medical record (COSTAR) in our academic group practice in pediatrics, and recorded data on 14,486 visits for preventive health care or illness over an 18-month period. Except when follow-up visits were made within 48 hours of an encounter, a complete medical record was available at all times. The attending staff physicians were enthusiastic about the computer-based record, and after a period of adaptation, the residents were as well. The nurses and clerical staff agreed that it improved office efficiency and thus patient care. Yet the system was abandoned in the face of medical college politics and problems in other practices at our institution.
高质量的医疗服务需要一份完整、清晰且随时可获取的病历。由于医疗服务系统的复杂性，学术团体诊所中的信息存储和检索往往比私人诊所更困难。我们在儿科的学术团体诊所实施了计算机化病历系统（COSTAR），并在18个月的时间里记录了14486次预防保健或疾病就诊的数据。除了在就诊后48小时内进行随访外，完整的病历随时可用。主治医生对基于计算机的病历很感兴趣，经过一段时间的适应，住院医生也一样。护士和文书工作人员一致认为它提高了办公效率，从而改善了患者护理。然而，面对医学院的政治因素以及我们机构其他诊所的问题，该系统被放弃了。
