Essin D J, Dishakjian R, deCiutiis V L, Essin C D, Steen S N
Department of Anesthesiology, Martin Luther King Hospital, Drew University, Los Angeles, CA, USA.
J Clin Monit Comput. 1998 Feb;14(2):95-100. doi: 10.1023/a:1007407912970.
Computerization of the medical record in various outpatient settings has been successful but for anesthesiologists, the preoperative visit differs significantly. This study implemented a computerized version of a structured preanesthetic evaluation questionnaire that we had previously developed and which provided a starting point for developing a suitable vocabulary and workflow. Using the computerized version, pre-anesthetic evaluations were performed on 26 obstetric patients over a 20-week period. The introduction of a computer into the physician-patient relationship did not disrupt the examination. It markedly reduced time-consuming tasks (such as dictation), captured far more detail than found in our previously dictated and handwritten notes and provided immediately available data for quality assurance activities.
在各种门诊环境中,病历的计算机化已经取得成功,但对于麻醉医生来说,术前访视有显著不同。本研究实施了我们之前开发的结构化麻醉前评估问卷的计算机版本,该版本为开发合适的词汇和工作流程提供了一个起点。使用该计算机版本,在20周内对26名产科患者进行了麻醉前评估。在医患关系中引入计算机并没有干扰检查。它显著减少了耗时的任务(如听写),获取的细节比我们之前听写和手写记录中的要多得多,并为质量保证活动提供了即时可用的数据。