Real “Time Entry and Display of Clinical Data in an Intensive Care Unit^[*])

A system for entry, storage and retrieval of textual information on the patient’s history and physical examination, as well as the physician’s progress notes, has been designed for use in a critical care environment: The system, which utilizes a digital computer, concurrently monitors signals from sensors measuring physiological parameters.

Textual information on the history and physical examination is entered into the computer by the physician or nurse using a bedside terminal. Coded formats are used to enter the data. Provision is also made for entry of comments in natural language and for formal structuring of answers by the use of selected comments from lists of answers. The information is stored on a disk as textual summaries which are interwoven with analog summaries.

Data on current patients, or on previous patients, are displayed on the terminal on request of the physician. This method of handling textual information provides a practical means of acquiring detailed clinical data and correlating it with physiological measurements, thereby facilitating rapid interpretation of changes in the status of the critically ill patient.

Verff. haben ein System zur Speicherung und Weiterverarbeitung textlicher Informationen über die Vorgeschichte und den Untersuchungsbefund sowie den Krankheitsverlauf von Patienten in einer Intensivpflegestation entwickelt. Das computerorientierte System überwacht gleichzeitig die Signale von Geräten, die physiologische Parameter erfassen.

Die Angaben zur Anamnese und zum Untersuchungsbefund werden vom Arzt oder der Krankenschwester über ein Terminal am Krankenbett in den Computer eingegeben. Die Dateneingabe erfolgt in codierter Form. Daneben ist es möglich, Kommentare in Klartext und formal strukturierte Antworten unter Benutzung vorgegebener Formulierungen aus Antwortenlisten einzugeben. Die textlichen Kurzfassungen werden gemeinsam mit ausgewählten Analogdaten auf der Platte gespeichert.

Die Daten über in Behandlung befindliche oder frühere Patienten können auf Anfrage des Arztes über das Terminal ausgegeben werden. Die hier entwickelte Methode der Datenbearbeitung erlaubt die Erfassung detaillierter Informationen und deren Verknüpfung mit physiologischen Meßwerten und erleichtert die schnelle Interpretation von Änderungen im Zustand von Schwerkranken.

Key-Words

Intensive Care Unit - On-Line Data Processing - Processing of Textual Information - Patient Monitoring

Schlüssel-Wörter

Intensivpflegestation - On-line-Datenverarbeitung - Textverarbeitung - Schwerkranken-Uberwachung.

^* This investigation was supported by a grant from The John A. Hartford Foundation, Inc., New York, grants HE 05570 and HE 07811_from the National Heart Institute, United States Public Health Service and grant HS 0023B from the Health Care Technology Program, United States Public Health Service.

Publication History

Publication Date:
10 February 2018 (online)

• References

• 1 Baird H. W, Garfunkel J. M. Electronic data processing of medical records. New Engl. J. Med 272 1965; 1211-1215.
• 2 Barnett O. G, Castleman P. A. A time-sharing computer system for patient-care activities. Comput. biomed. Res 03 1967; 41-50.
• 3 Collen M. F. Periodic health examinations using an automated multitest laboratory. J. Amer. med. Ass 195 1966; 830-833.
• 4 Collen M. F, Linden C. Screening in a group practice prepaid medical care plan. J. chron. Dis 02 1955; 400-407.
• 5 Davis L. S, Collen M. F, Rubin L, VanBrunt E. E. Computer-stored medical record. Comput. biomed. Res 03 1968; 452-469.
• 6 Juergens J. L, Kiely J. M. Physician entry of cardiac physical findings into a computer based medical record. Proc. Mayo Clin 44 1969; 361-366.
• 7 Kiely J. M, Juergens J. L, Hisey B. L, Williams P. E. A computer-based medical record: Entry of data from history and physical examination by the physician. J. Amer. med. Ass 205 1968; 571-576.
• 8 Kohein J, Goodgold A. L, Randt C. T. Computer processing of medical data of variable-field-length format. II. Progress and application to narrative documents. J. Amer. med. Ass 396 1966; 950-963.
• 9 Kohein J, Tick L. J, Woodbury M. A, Cady L. D, Goodgold A. L, Randt C. T. Computer processing of medical data by variable-field-length format. J. Amer. med. Ass IBS 1963; 132-138.
• 10 Lenoski E. F, Hanes B, Wingeht W. A. Computer processing of pediatric emergency room data. J. Amer. med. Ass 204 1968; 797-804.
• 11 Lindberg D AB. Electronic retrieval of clinical data. J. med. Educ 40 1965; 753-759.
• 12 Mayne J. G, Weksel W, Sholtz P. N. Toward automating the medical history. Proc. Mayo Clin 43 1968; 1-25.
• 13 Slack W. V, VanCura L. J. Patient reaction to computer-based medical interviewing. Comput. biomed. Res 03 1968; 527-531.
• 14 Stewart D. H, Ebbeck D. H, Shubin H. A Computer System for Real-Time Monitoring and Management of the Critically III. in AFIPS Conference Proceedings, Fall Joint Computer Conference, Dec. 9–11, 1968, San Francisco, Calif. 797-801 Thompson; Washington, D. C: 1968
• 15 Weed L. L. Medical records that guide and teach. New Engl. J. Med 278 1968; 593-600 652–657.
• 16 Weil M. H. Circulatory Shock — A Symposium on Advances in the Understanding of Mechanisms and Treatment. Calif. Med 103 1965; 310-320.
• 17 Weil M. H. Circulatory Shock — A Symposium on Advances in the Understanding of Mechanisms and Treatment. Calif. Med 106 1967; 1-11.
• 18 Weil M. H. Circulatory Shock — A Symposium on Advances in the Understanding of Mechanisms and Treatment. J. Trauma 09 1969; 140-156.
• 19 Weil M. H, Siiubin H. (Eds) Diagnosis and Treatment of Shock. Williams & Wilkins; Baltimore: 1967