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在专科妇科实践中,通过两阶段问卷调查并自动转录获取病史。

Histories obtained by two-stage questionnaire with automated transcript in specialist gynaecological practice.

作者信息

Robinson D W, Walmsley G L, Horrocks J C, Milson P, Jenkins D M, De Dombal F T, Scott J S

出版信息

Br Med J. 1975 Nov 29;4(5995):510-3. doi: 10.1136/bmj.4.5995.510.

Abstract

A two-stage questionnaire which the patient completes at home has been developed for use by gynaecological outpatients. The first stage (root) identifies the patient's problem and obtains general background information. The second stage (branch) deals with the presenting problem in depth. The system has proved highly acceptable to patients. At the clinic a non-medical assistant uses a programmed typewriter to transcribe the data into a typewritten history which is handed to the doctor before he examines the patient. The transcript compares favourably with the conventional hand-written history in content, ease of assimilation, and cost. While the questionnaire itself is an excellent means of collecting information it becomes an efficient means of transmitting information to the clinician only when combined with the transcript facility. There is no storage of confidential information and no scope for unethical disclosure.

摘要

已开发出一种供妇科门诊患者在家中填写的两阶段问卷。第一阶段(根部)识别患者的问题并获取一般背景信息。第二阶段(分支)深入处理当前问题。该系统已被证明很受患者欢迎。在诊所,一名非医疗助理使用程控打字机将数据转录成打印病史,在医生检查患者之前交给医生。这份转录件在内容、易于理解程度和成本方面与传统手写病史相比毫不逊色。虽然问卷本身是收集信息的极佳方式,但只有与转录功能相结合时,它才成为向临床医生传递信息的有效方式。不存在机密信息存储问题,也没有不道德披露的空间。

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本文引用的文献

1
A computer-based medical-history system.一个基于计算机的病史系统。
N Engl J Med. 1966 Jan 27;274(4):194-8. doi: 10.1056/NEJM196601272740406.
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The diagnostic process.诊断过程。
J R Coll Physicians Lond. 1970 Apr;4(3):183-7.
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Self-administered clinical questionnaire for outpatients.门诊患者自我管理临床问卷。
Br Med J. 1974 Apr 27;2(5912):209-12. doi: 10.1136/bmj.2.5912.209.
9
Letter: Reliability of the history.信函:病史的可靠性。
Lancet. 1975 Jan 11;1(7898):103. doi: 10.1016/s0140-6736(75)91109-5.

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