The Computerized Problem-Oriented Medical Record at Karolinska Hospital — Format and Function, Users’ Acceptance and Patient Attitude to Questionnaire —

Ch. Mellner; H. Selander; J. Wolodarski

doi:10.1055/s-0038-1635721

Methods of Information in Medicine, Inhaltsverzeichnis

Methods Inf Med 1976; 15(01): 11-20
DOI: 10.1055/s-0038-1635721

Original Article

The Computerized Problem-Oriented Medical Record at Karolinska Hospital — Format and Function, Users’ Acceptance and Patient Attitude to Questionnaire —

DAS COMPUTERGERECHTE, PROBLEMORIENTIERTE KRANKENBLATT IM KARO-LINSKA-KRANKENHAUS —FORMAT UND FUNKTION, EINSTELLUNG VON BENUTZERN UND HALTUNG DER PATIENTEN ZU DEM FRAGEBOGEN —

Autoren

Ch. Mellner
H. Selander
J. Wolodarski

¹Departments of Medical Information and Thoracic Medicine, Karolinska Hospital, Stockholm, Sweden

Abstract

In the last five years computerized medical records have come into routine use at some departments of the Karolinska Hospital. These records were to a large extent based on the problem-oriented approach.

This paper describes the format and function of this record, reports the acceptability thereof to the users compared to the traditional source-oriented medical record, and discusses patient attitudes to the questionnaire method for medical history-taking.

In den letzten fünf Jahren werden in einigen Abteilungen des Karolinska-Krankenhauses computergerechte Krankenblätter routinemäßig erstellt. Zum großen Teil sind diese Krankenblätter problemorientiert angelegt.

Die Autoren beschreiben Format und Funktion dieses Krankenblattes, berichten, wie es im Vergleich zum herkömmlichen, quellenorientierten Krankenblatt angenommen wird, und erörtern die Haltimg der Patienten gegenüber der Fragebogenmethode zur Anamneseerhebung.

Key-Words

Computerized Problem-oriented Medical Record - History Taking - Questionnaire

Schlüssel-Wörter

Problemorientiertes Krankenblatt - Anamneseerhebung - Fragebogen

Volltext

Referenzen

References
1 Berlin R. Rapport över datajournalprojekt (Spri-projekt 204) vid medicinska kliniken, Regionsjukhuset, Linköping. Report, December 1969.
2 Biörck G. Spri-report 7089 (1974).
3 Bjorn J. C, Cross H. D. Problem oriented Practice. Chicago: Modern Hospital Press, McGraw-Hill Publications; 1970
4 Bryan T, Summers R. How to Start Using the Problem- Oriented Medical Record. J. Iowa Med. Soc 62 1972; 183-186.
5 Crawford G. B. The Problem-Oriented Medical Record in Long-Term Institutional Care. J. Amer. Geriat. Soc 21 1973; 465-468.
6 Cross H. D. Educational Needs as Determined by the Problem-Oriented Medical Record. J. Maine med. Ass 61 1970; 49-54.
7 Dinsdale S. M, Mossman P. L, Gullickson Jr. G, Anderson T. The Problem-Oriented Medical Record in. Rehabilitation. Arch. Phys. Med 51 1970; 488-492.
8 Feinstein A. R. The Problems of the »Problem-Oriented Medical Record«. Ann. intern. Med 78 1973; 751-762.
9 Fletcher R. H. Auditing Problem-Oriented Records and Traditional Records. New Engl. J. Med 290 1974; 829-833.
10 Gardner L. B. The Problem-Oriented Record in Critical Care Medicine. Chest 62 1972; 8-698
11 Gilandas A. J. The Problem-Oriented Record in a Psychiatric Hospital. Hosp. Community Psych 23 1972; 336-339.
12 Goldfinger S. E. The Problem-Oriented Record: A Critique from a Believer. New Engl. J. Med 288 1973; 006-608.
13 Grossman J. H, Barnett G. O, McGuire M. T, Swedlow D. B. Evaluation of Computer-Acquired Patient Histories. J. Amer. med. Ass 215 1971; 1286-1291.
14 Haeger K, Engkvist O, Danielsson T, Hall P, Mellner Ch. Datamaskinell journalföring och »driftskontroll« vid en kirurgisk klinik. Preliminära erfarenheter. (Computerized Medical Records and Production Control at a Surgical Department. Preliminary Results). Läk.-Tidn 62 1965; 4239-4247.
15 Haessler H. A, Holland E, Errol L. E. Evolution of an Automated Database History. Arch, intern. Med 134 1974; 586-591.
16 Hall P, Selander H. Problemorienterad journal. Läk.- Tidn 67 1970; 3373-3379.
17 Hanngren Å, Mellner Ch. Försöksvis införande av ett medicinskt Informationssystem vid Thoraxmedieinska kliniken. Report, June 1972.
18 Hurst J. W. The Problem-Oriented Record and the Measurement of Excellence. Arch, intern. Med 128 1971; 818-819.
19 Hurst J. W. Ten Reasons why Lawrence Weed is Right. New Engl. J. Med 284 1971; 51-52.
20 Jervey A. J. On the Use of Problem-Oriented Medical Records. Alaska Med. (April 1972) 59—61.
21 Kanner I. F. Programmed Medical History-Taking with or without Computer. J. Amer. med. Ass 207 1969; 317-321.
22 Margolis C, Sheehan J, Stickley W. A Graded Problem-Oriented Record to Evaluate Clinical Performance. Pediatrics 51 1973; 980-985.
23 Maultsby Jr. M. C, Slack W. V. A Computer-Based Psychiatry History System. Arch. gen. Psychiat 25 1971; 570-572.
24 Mayne J. G, Weksel W, Sholtz P. N. Toward Automating the Medical History. Mayo Clin. Proc 43 1968; 1-24.
25 Mayne J. G, Martin M. J. Computer-Aided History Acquisition. Med. Clin. N. Amer 54 1970; 825-833.
26 McIntyre N. The Problem-Oriented Medical Record. Brit, med. J 1973; II: 598-600.
27 McLean E. R, Rockart J. F, Chaney J. H. Questionnaire Becomes Preadmission Tool. Hospitals 47 1973; 56-59.
28 Mellner Ch, Selander H, Wolodarski J. The Karolinska Hospital Information System. Part I. Information Requirements in Health Care Delivery and the Approach to Systems Design at the Karolinska Hospital. Meth. Inform. Med 13 1974; 125-128.
29 Mellner Ch, Selander H, Wolodarski J. The Karolinska Hospital Information System. Part II. The Data Base and Data Processing System. Meth. Inform. Med 13 1974; 129-137.
30 Milhous R. The Problem-Oriented Medical Record in Rehabilitation Management and Training. Arch. phys. Med 53 1972; 182-185.
31 Novello J. R. The Problem-Oriented Record in Psychiatry. J. ment. Dis 156 1973; 349-353.
32 Potts L. R. The Problem-Oriented Record: Implications for Occupational Therapy. Amer. J. occup. Ther 26 1972; 288-291.
33 Problem-Oriented Medical Records. Editorial. Lancet 1972; I: 295-296.
34 Saitz E. W, Lewis K. H. Use of the Problem-Oriented Record by Junior Medical Students in Pediatric Ambulatory Care. J. med. Educ 48 1973; 453-455.
35 Selander H. Patient Identification. Proc. IFIP Conf. Inf. Proc. Med. Records. Lyon: 1970: 71-81.
36 Simmons Jr. E. M, Miller O. W. Automated Patient History-Taking. Hospitals 45 1971; 56-59.
37 Sjukhusrationalisering med Automatisk Databehandling. Rapport om försöksverksamhet vid karolinska sjukhuset. 1970: 1-397.
38 Slack W. V, Hicks G. P, Reed C. E, Van Cura L. J. A Computer-Based Medical History System. New Engl. J. Med 274 1966; 194-198.
39 The Challenge and the Opportunities of the Weed System. Editorial. Arch, intern. Med 128 1971; 832-834.
40 Tudor Jr. J. M. The Problem-Oriented Method in Family Practice. J. Ark. med. Soc 68 1972; 289-293.
41 Weed L. L. Medical Records that Guide and Teach. New Engl. J. Med 278 1968; 593-600 652—657.
42 Weed L. L. What Physicians Worry about: How to Organize Care of Multiple-Problem Patients. Mod. Hosp 110 1968; 90-94.
43 Weed L. L. Medical Records, Medical Education, and Patient Care: The Problem-Oriented Record as a Basic Tool. Cleveland: Press of Case Western Reserve University; 1969
44 Weiss J. J, Yanez J. The Problem Oriented Record. A New Approach to Total Patient Care. Med. Times 98 1970; 135-143.
45 Woody M, Mallison M. The Problem-Oriented System. Amer. J. Nurs 73 1973; 1168-1175.