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国际初级保健分类法(ICPC - 2):全科医生电子病历中的重要工具。

The International Classification of Primary Care (ICPC-2): an essential tool in the EPR of the GP.

作者信息

Verbeke Marc, Schrans Diëgo, Deroose Sven, De Maeseneer Jan

机构信息

Department of General Practice and Primary Health Care, Ghent University, Belgium.

出版信息

Stud Health Technol Inform. 2006;124:809-14.

Abstract

The International Classification of Primary Care (ICPC) has become a standard all over the world. It became a standard tool to classify the important elements in the Electronic Patient Record (EPR) of the GP: reasons for encounter (RFE) reflecting the patient's view, process of care (decision, action, intervention or plans) reflecting the care process, and the assessment (diagnosis or health issue) reflecting the doctor's view. ICPC-2 is fully compatible with structuring data in the episode of care model and it's reflecting the essential elements of each patient/provider encounter. To implement ICPC-2 in the EPR a Thesaurus has been developed in Belgium with double encoded clinical labels. The implementation is now mandatory for labeled EPR systems in Belgium. The use of ICPC 2 ay improve the accessibility and use of on-line Expert systems and Guidelines.

摘要

国际初级保健分类法(ICPC)已成为全球标准。它成为了对全科医生电子病历(EPR)中的重要元素进行分类的标准工具:反映患者观点的就诊原因(RFE)、反映护理过程的护理过程(决策、行动、干预或计划)以及反映医生观点的评估(诊断或健康问题)。ICPC - 2与护理事件模型中的数据结构化完全兼容,并且它反映了每次患者/提供者接触的基本要素。为了在EPR中实施ICPC - 2,比利时开发了一个带有双重编码临床标签的词库。现在,比利时对标有标签的EPR系统强制实施该标准。使用ICPC 2可能会提高在线专家系统和指南的可及性和利用率。

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