Rodnick J E
J Fam Pract. 1977 Aug;5(2):253-64.
An extensive survey of the uses of computerized automated ambulatory medical record systems has been conducted. The medical services provided which seem to offer the greatest benefits include: patient profiles which are a concise summary of a patient's medical status, patient surveillance to help in preventive care and management of chronic disease, data presentation by flow sheets and graphs, and data-base searches for audit, training, and research. The close integration of medical data with patient management and administrative services such as scheduling, registration, and financial systems, gives valuable utilization and practice information. Improvement in the billing and accounting process is in itself a most important benefit. In addition, the collection and analysis of medical data for health services research, quality of care audits, and training of future providers offers much potential. A number of innovative and economically viable computerized ambulatory record systems are currently operating.
已经对计算机化自动门诊病历系统的使用情况进行了广泛调查。所提供的医疗服务似乎带来最大益处的包括:患者概况,它是患者医疗状况的简明摘要;患者监测,有助于预防保健和慢性病管理;通过流程图和图表呈现数据;以及为审计、培训和研究进行数据库搜索。医疗数据与患者管理以及诸如调度、登记和财务系统等行政服务的紧密整合,提供了有价值的利用和实践信息。计费和会计流程的改进本身就是一项极其重要的益处。此外,为卫生服务研究、护理质量审计以及未来医疗服务提供者的培训收集和分析医疗数据具有很大潜力。目前有一些创新且经济可行的计算机化门诊记录系统正在运行。