Walker C H
Arch Dis Child. 1977 Jun;52(6):452-61. doi: 10.1136/adc.52.6.452.
To use a combined single document clinical case sheet/computer record which can form the basic document for a life medical record is a practical proposition. With adequate briefing doctors and nurses soon become familiar with the record and appreciate its value. Secretarial and clerical requirements are reduced to a minimum as transcription of medical data is eliminated, so greatly speeding up processing and feed back to the medical services. A few illustrations of trends in neonatal statistics and of computer linked maternal/neonatal data are presented.
使用一份综合的单文档临床病例表/计算机记录作为终身医疗记录的基础文档是一个切实可行的方案。经过充分的培训,医生和护士很快就能熟悉该记录并认识到其价值。由于无需转录医疗数据,秘书和文书工作的需求降至最低,从而大大加快了处理速度并反馈给医疗服务部门。文中给出了一些新生儿统计趋势以及计算机连接的母婴/新生儿数据的示例。