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Methods Inf Med 1977; 16(01): 24-27
DOI: 10.1055/s-0038-1636571
Original Article
Schattauer GmbH

Medical Record Summary for Computer Operation

ZUSAMMENFASSUNG DES KRANKENBLATTS FÜR DIE COMPUTERVERARBEITUNG
B. L. Gordon
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Publication History

Publication Date:
14 February 2018 (online)

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Key items of the source medical record are valuable in computing, notably when presented in a wellordered summary. These designations are preferred to complete coverage and narration. The computer file includes patient identification, reasons for the consultation, findings, treatment, outcome and successive episodes and/or observations; academic diagnoses are desirable if/when proved. Descriptors or nouns and qualifiers or adjectives constitute the computer vocabulary for key items, e.g., paincliest-precordium-sudden-severe-radiation-chin, ECG inverted T wave. Random numbers are useful to attain maximum simplicity and specificity of the input for filing, handling, timely communication and subsequent classification.

Schlüsselwörter des Originalkrankenblattes sind wertvoll für die Computerverarbeitung, besonders wenn sie in einer wohlgeordneten Zusammenfassung präsentiert werden. Diese Bezeichnungen sind einem vollständigen Bericht vorzuziehen. Die Computerdatei enthält die Patientenidentifizierung, die Gründe für die Konsultation, Befund, Behandlung, Ergebnis und katamnestische Episoden und/oder Beobachtungen; akademische Diagnosen sind wünschenswert, soweit gesichert. Deskriptoren bzw. Substantiva und Modifikatoren bzw. Adjektiva machen das Computervokabular für Sehlüsselbegriffe aus, z.B. Schmerz-Brust-Epigastrium-plötzlich-heftig-Bestrahlung-Kinn, EKG-invertierte T-Welle. Zufallszahlen sind nützlich zur Erreichung größtmöglicher Einfachheit und Spezifizität der Eingabe für Verarbeitung, Handhabung, zeitgerechte Kommunikation und nachfolgende Klassifikation.

Key-Words

Medical Record Processing - Current Medical Information and Terminology (CMIT) - Simplified Medical Records System (SMRS)

Schlüssel-Wörter

Krankenblattverarbeitung - Current Medical Information and Terminology (CMIT) - Simplified Medical Records System (SMRS)
 

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