Written records and first-generation hospital information systems do not meet their primary purpose to assist physicians in solving patients' problems. Simply automating the present chart formats is not the answer. An example of the concept needed for charting is the intensive care unit chart. ⋯ Automation of the anesthesia record should free the anesthesiologist of the need to search for preoperative information and to manually record most information intraoperatively. Decisions about how much data to archive and how to extract the data pertinent to continuing care are the challenges for physicians. The technologic tools are available for the design and implementation of a software system that focuses on effective communication of the patient's problems throughout the perioperative period as the patient moves from ward to operating room, through the recovery room and intensive care unit, and to the ward and home.
Department of Surgery, University of California, San Diego 92103.
J Clin Monit. 1989 Oct 1; 5 (4): 266-9.
AbstractWritten records and first-generation hospital information systems do not meet their primary purpose to assist physicians in solving patients' problems. Simply automating the present chart formats is not the answer. An example of the concept needed for charting is the intensive care unit chart. Anesthesiology charts provide little useful information for the continued care of the patient postoperatively. They serve principally as legal archival documents. Automation of the anesthesia record should free the anesthesiologist of the need to search for preoperative information and to manually record most information intraoperatively. Decisions about how much data to archive and how to extract the data pertinent to continuing care are the challenges for physicians. The technologic tools are available for the design and implementation of a software system that focuses on effective communication of the patient's problems throughout the perioperative period as the patient moves from ward to operating room, through the recovery room and intensive care unit, and to the ward and home.