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非医生人员根据办公室记录制定问题清单。

Non-physician development of problem lists from office records.

作者信息

Reed D E, Lapenas C, deVries J R, Watterson S G, Caton R

出版信息

J Fam Pract. 1975 Jun;2(3):211-2.

PMID:1080183
Abstract

It has been argued that conversion of office records to the problem-oriented medical record entails a prohibitive cost in money and physician time. This study reports an evaluation of the cost of preparing problem lists from existing ambulatory patient records by non-physician personnel. The problem lists constructed by non-physician personnel were judged by physicians to be accurate, and the cost was much less than that required when physicians reviewed charts and prepared problem lists themselves. The method described here is an accurate and cost-effective way to begin conversion of outpatient records to P.O.M.R.

摘要

有人认为,将办公室记录转换为问题导向型病历在金钱和医生时间方面需要高昂成本。本研究报告了对非医生人员根据现有门诊患者记录编制问题清单的成本评估。医生认为非医生人员编制的问题清单准确无误,且成本远低于医生自己查阅病历并编制问题清单所需的成本。这里描述的方法是将门诊记录转换为问题导向型病历的一种准确且具有成本效益的开端方式。

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