Hayes G M
Primary Health Care Specialist Group, British Computer Society.
Proc AMIA Annu Fall Symp. 1996:454-8.
This paper considers the lessons learnt during the development of the electronic medical record for patient care. It is not a definitive history of medical records but an assessment of what has been learnt, what has to be learnt and how we can move forward. It considers the needs for structured intelligent records that help in individual patient care, the need to provide functionality that fits with the requirements of the clinician-patient interaction and the need to take into account the human factors that affect clinician's uptake of such systems. It outlines the issues of free form input as opposed to controlled input that have to be resolved.
本文探讨了在开发用于患者护理的电子病历过程中所汲取的经验教训。它并非医疗记录的详尽历史，而是对已学到的、有待学习的以及我们如何向前发展的评估。它考虑了对有助于个体患者护理的结构化智能记录的需求，提供符合临床医生与患者互动要求的功能的需求，以及考虑影响临床医生采用此类系统的人为因素的需求。它概述了与必须解决的受控输入相对的自由形式输入的问题。
