van Ginneken A M, Stam H, Moorman P W
Department of Medical Informatics, Erasmus University, Rotterdam, The Netherlands.
Int J Biomed Comput. 1996 Jul;42(1-2):21-6. doi: 10.1016/0020-7101(96)81525-x.
Despite a number of well recognized shortcomings of paper medical records, the use of a Computer Patient Record (CPR) is not widespread among specialists. The complexity of specialized care combined with the diversity of their domains of expertise, make it a challenge to design a CPR that satisfies the needs of a specialist. Ideally, CPRs are tailored to the specific tasks of each user, and yet general enough to permit exchange and sharing of information. The basic philosophy behind our CPR is a 'mother' record, which is extended with specialized sub-records. Two different types of subrecords are discussed: one to accommodate standardized data entry in the context of a specialty or research protocol, and another for structured recording of accidental findings outside one's own domain of expertise. The CPR supports the entry of free text and does not impose structured data entry on the physician, but stimulates him to do so by confronting him with the benefits of a structured CPR.
尽管纸质病历存在一些公认的缺点，但计算机化病人记录（CPR）在专科医生中并未广泛使用。专科护理的复杂性加上其专业领域的多样性，使得设计出满足专科医生需求的CPR成为一项挑战。理想情况下，CPR应针对每个用户的特定任务进行定制，但又要足够通用以允许信息的交换和共享。我们的CPR背后的基本理念是一个“母”记录，并通过专门的子记录进行扩展。讨论了两种不同类型的子记录：一种用于在专科或研究方案的背景下进行标准化数据录入，另一种用于在自己专业领域之外对偶然发现进行结构化记录。CPR支持自由文本录入，不对医生强制要求结构化数据录入，而是通过向他展示结构化CPR的好处来激励他这样做。
