产前护理信息管理:问题清单与临床意见整合。

Josephine Miller, Catherine Driscoll, Sarah Kilpatrick, Edmond Quillen
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引用次数: 0

摘要

为了改善我们的产妇记录系统(MARS)的功能,我们从大约2800例患者记录中回顾了进入MARS数据库的临床问题,并采访了具有代表性的临床医生,了解他们对MARS的临床评论和问题列表部分的使用情况。问题被分配了一个独特的术语,用于纠正拼写、间距、同义词和缩写变化。对这些术语的分析表明,设计变更将增加问题列表中唯一条目的数量,包括(1)修改MARS中的自动问题输入功能和(2)问题列表和临床评论部分的集成。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Management of prenatal care information: integration of the problem list and clinical comments.

To improve the functionality of our MAternal Record System (MARS), we reviewed the clinical problems entered into the MARS database from approximately 2800 patient records and interviewed representative clinicians about their use of the Clinical Comments and Problem List sections of MARS. Problems were assigned a unique term that corrected for spelling, spacing, synonyms, and abbreviation variations. Analysis of these terms suggested design changes that would increase the number of unique entries into the Problem List, including (1) modifications in the automated problem entry functions within MARS and (2) integration of the Problem List and Clinical Comments sections.

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