[Information technology and medical record routines in hospitals in the health care region 2]. / Informasjonsteknologi og journalrutiner ved sykehus i helseregion 2.

Structure, standard and efficient methods in paper medical records are important for a successful implementation of computerised medical records. We have conducted a survey among 26 somatic hospitals in a Norwegian region regarding present routines and use of information technology in patients records. The hospitals use six different patient administration systems, six laboratory, six radiology, and approximately 20 different specialist systems. 16 hospitals use three different electronic journal/documentation systems. Ten hospitals use the Word word processor for patient records. The full potential of word processing is not utilised. Digital dictation is seldom used; few hospitals have 24-hours service for documentation, and information technology is not used for documentation in nursing care. Four hospitals use microfilm. The survey shows that improvement is needed in order to achieve coordinated and effective use of information technology and manual routines in hospital medical records.

Long-term results of bilateral stapedectomy.

Bilateral stapedectomy was performed in 122 cases of bilateral otosclerosis at Ulleval Hospital between 1960 and 1978. Ninety-six patients (192 ears), or 79 per cent, were re-examined in 1980. The long-term results showed that the air/bone gap was closed to within 10 db. in 142 ears (74 per cent). Twenty-four patients (25 per cent) used a hearing aid at the time of the examination, mainly because of presbyacusis. Deafness or serious sensori-neural loss ascribed to the operation was found in 21 ears (11 per cent). Immediate deafness occurred in three ears (1.5 per cent), and in seven ears (3.7 per cent) the patient became deaf later. Eleven ears (5.8 per cent) had marked sensori-neural losses, but with some speech comprehension. None of the patients had bilateral deafness, but one patient was deaf in one ear, with a sensori-neural loss of 80 db. in the other. Eleven patients (13 ears) who had undergone previous stapediolysis or crurotomy, were treated as a separate group, and their results were compared with those obtained in the other patients. We have also tried to find out if there is any difference between the long-term results of surgery in the first and in the second ear.