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农村医疗环境下病历的实用处理方法。

A practical approach to medical records in a rural health care setting.

作者信息

Tatro P

出版信息

J Rural Health. 1987 Jan;3(1):15-9. doi: 10.1111/j.1748-0361.1987.tb00154.x.

Abstract

Deciding on a system for keeping medical records in a new rural health practice, or in an established practice seeking to update an obsolete system, may be confusing because of a multitude of vendors who claim to meet every need. Special circumstances set rural practices apart from other ambulatory care settings with regard to medical record needs. Practical consideration regarding filing systems, record content and format are offered in view of these special circumstances. Issues involving ownership of the record and access to confidential information are also explored.

摘要

在新建的农村医疗诊所,或是在寻求更新过时系统的现有诊所中,决定采用何种医疗记录保存系统可能会令人困惑,因为众多供应商声称能满足各种需求。在医疗记录需求方面,特殊情况使农村诊所有别于其他门诊护理机构。鉴于这些特殊情况,本文针对档案系统、记录内容和格式提供了实际考量。还探讨了涉及记录所有权和获取机密信息的问题。

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