Teich J M, Spurr C D, Schmiz J L, O'Connell E M, Thomas D
Department of Information Systems, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Proc Annu Symp Comput Appl Med Care. 1995:459-63.
Physician-operated order entry systems can bring great benefits to an institution. Such systems can improve the consistency, accuracy, safety, and cost-effectiveness of orders. When building or selecting order entry for an institution, consideration must be given to the many different scenarios in which orders are written and communicated. Transfer, post-op, pre-admission and discharge orders have different communication requirements from standard inpatient orders. In certain services, orders from a very limited set (such as warfarin orders) must be written frequently for a large number of patients. Intensive-care patients, chemotherapy patients, and others have particular requirements for ordering. A computerized order entry system should respond to these requirements in order to promote correct and efficient ordering. We present a number of these issues, their specific requirements, and the approach we have taken to ensure that the system both supports and enhances workflow.
医生操作的医嘱录入系统能给机构带来巨大益处。此类系统可提高医嘱的一致性、准确性、安全性及成本效益。在为机构构建或选择医嘱录入系统时,必须考虑医嘱书写和传达的诸多不同场景。转科、术后、入院前及出院医嘱与标准住院医嘱有不同的沟通要求。在某些科室,针对大量患者需频繁开具来自非常有限的一组医嘱(如华法林医嘱)。重症监护患者、化疗患者及其他患者对医嘱有特殊要求。计算机化医嘱录入系统应满足这些要求,以促进正确且高效的医嘱开具。我们阐述其中一些问题、它们的具体要求以及我们为确保系统既能支持又能优化工作流程所采取的方法。