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一份患者记录能否适应专科护理的多样性?

Can one patient record accommodate the diversity of specialized care?

作者信息

van Ginneken A M, Stam H

机构信息

Department of Medical Informatics, Erasmus University, Rotterdam, The Netherlands.

出版信息

Proc Annu Symp Comput Appl Med Care. 1995:406-10.

Abstract

Despite a quarter century of developments, few specialists directly use a computerized patient record, that fully replaces the paper chart. Because of the diversity of domains in specialized care, medical decision-making and the continuity of care may suffer from scattering of patient data over various records. The challenge was to develop a computerized patient record, that would be versatile enough to tailor it to specific needs, while keeping it uniform enough to permit physicians to share data on the same patient. In our CPR, the key that reconciles versatility with uniformity lies in the design of the data model. The CPR consists of a mother record with specialized sub-records, that all share the same data model. A physician can enlarge his scope for decision-making by consulting other specialized records on the same patient or by viewing the combined information of all sub-records without the need to convert data or to familiarize himself with different interfaces.

摘要

尽管经过了25年的发展,但很少有专家直接使用能完全取代纸质病历的计算机化患者记录。由于专科护理领域的多样性,医疗决策和护理的连续性可能会因患者数据分散在各种记录中而受到影响。挑战在于开发一种计算机化患者记录,它要足够通用,能根据特定需求进行定制,同时又要足够统一,以便医生能够共享同一患者的数据。在我们的计算机化患者记录(CPR)中,使通用性与统一性相协调的关键在于数据模型的设计。CPR由一个主记录和多个专门的子记录组成,所有这些记录都共享相同的数据模型。医生可以通过查阅同一患者的其他专门记录,或者查看所有子记录的综合信息来扩大其决策范围,而无需转换数据或熟悉不同的界面。

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