DeFriece R J
Division of Medical Informatics, Duke University Medical Center, Durham, NC, USA.
Proc Annu Symp Comput Appl Med Care. 1995:91-5.
Capturing clinical data is a multi-faceted problem. This paper discusses clinical data entry problems encountered during the development of an intelligent clinical data entry system. Based on a review of the problems, recommendations are made for an approach to the design of clinical data entry programs. These recommendations include a discussion of key components in the design process as illustrated by the development of MedIO, a C++ computer program for the entry of history and physical exam information.
获取临床数据是一个多方面的问题。本文讨论了在开发智能临床数据录入系统过程中遇到的临床数据录入问题。基于对这些问题的回顾，针对临床数据录入程序的设计方法提出了建议。这些建议包括对设计过程中关键组件的讨论，MedIO的开发对此进行了说明，MedIO是一个用于录入病史和体格检查信息的C++计算机程序。
