病历记录标准。
Standards in medical record keeping.
作者信息
Mann Robin, Williams John
机构信息
Health Informatics Unit, Royal College of Physicians, London.
出版信息
Clin Med (Lond). 2003 Jul-Aug;3(4):329-32. doi: 10.7861/clinmedicine.3-4-329.
Medical records serve many functions but their primary purpose is to support patient care. The RCP Health Informatics Unit (HIU) has found variability in the quality of records and discharge summaries in England and Wales. There is currently a major drive to computerise medical records across the NHS, but without improvement in the quality of paper records the full benefits of computerisation are unlikely to be realised. The onus for improving records lies with individual health professionals. Structuring the record can bring direct benefits to patients by improving patient outcomes and doctors' performance. The HIU has reviewed the literature and is developing evidence-based standards for record keeping including the structure of the record. The first draft of these standards has been released for consultation purposes. This article is the first of a series that will describe the standards, and the evidence behind them.
医疗记录有多种功能，但其主要目的是支持患者护理。英国皇家内科医师学会健康信息学部门（HIU）发现，英格兰和威尔士的病历及出院小结质量存在差异。目前，整个英国国家医疗服务体系（NHS）正大力推动医疗记录电子化，但如果纸质记录的质量得不到改善，电子化带来的全部益处就不太可能实现。改善记录的责任在于个体医疗专业人员。构建记录结构可通过改善患者治疗效果和医生表现直接造福患者。HIU已查阅文献，并正在制定基于证据的记录保存标准，包括记录结构。这些标准的初稿已发布以供咨询。本文是系列文章中的第一篇，将介绍这些标准及其背后的证据。
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