[Up-to=date view on medical documentation in surgical clinic].
Computer variants of the fragments of clinical records were developed. They represent the parts: "Title-page", "Examination of surgical patient in the admission department", "Protocol of laparoscopic cholecystectomy". During modelling of the intellectual contents of the modules the principle of the formalized protocol was used, which has been realized with use of a context-depending menu. According to the authors opinion, newly developed programs provide objective and correct reflection of any clinical and surgical situation, use of standardized terminology and classifications, save the surgeons the trouble of "scribbling" and decrease time-consuming registration of medical records, provide specialized information, prevent possible diagnostic and technical errors, and give physicians, legal defence.
Kriger
A G
AG
Nechipaĭ
A M
AM
Fedorov
A V
AV
Glushkov
P S
PS
D004282:Documentation / Q000379:methods*; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000458:organization & administration* / Q000592:standards; D013503:Surgery Department, Hospital; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*