Möller T R, Gustafsson T
Comput Programs Biomed. 1977 Jun;7(2):117-24. doi: 10.1016/0010-468x(77)90018-6.
Based on a structured medical record, specially designed for patients with malignant disease, an on-line data capture system has been developed. This enables the collection of virtually any type of information contained in the patient's case notes. The structure of the record is described, with actual examples. The record is typed on a typewriter terminal linked to a mini-computer. Data is recorded as code + heading + value string. The headings are identified automatically, and an internal code generated, describing the type of information. Record keeping according to the principles described was introduced in clinical routine at the department in 1971. Data collection was implemented later that year, using an off-line magnetic tape encoder (IBM MT72). The system has been developed further and converted to a versatile on-line system. The data base, collected with these systems, now contains data on about 20,000 patients.
基于专门为恶性疾病患者设计的结构化病历,开发了一种在线数据采集系统。这使得能够收集患者病历中几乎任何类型的信息。文中通过实际例子描述了病历的结构。病历在与小型计算机相连的打字机终端上录入。数据记录为代码+标题+值字符串。标题会自动识别,并生成一个描述信息类型的内部代码。按照所述原则进行的记录保存于1971年在该科室的临床常规中引入。同年晚些时候,使用离线磁带编码器(IBM MT72)进行了数据采集。该系统已进一步开发并转换为通用在线系统。通过这些系统收集的数据库现在包含约20000名患者的数据。