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基层医疗信息系统中的非分类问题列表

Non-categorical problem lists in a primary-care information system.

作者信息

Wilton R

机构信息

Department of Pediatrics, UCLA School of Medicine.

出版信息

Proc Annu Symp Comput Appl Med Care. 1991:823-7.

PMID:1807721
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC2247645/
Abstract

An ambulatory-care patient-tracking system has been implemented that records non-categorical problem descriptions in the outpatient problem list. The system does not restrict physicians to the use of predefined diagnostic categories. Instead, the system stores patient problems in a database as free-text records. Subsequent diagnostic categorization and coding is accomplished through prompted free-text input and appropriate reference databases. This system design allows an outpatient problem-list summary to reflect non-categorical health-status information in addition to coded medical diagnoses.

摘要

一个门诊护理患者跟踪系统已实施，该系统在门诊问题列表中记录非分类的问题描述。该系统不限制医生使用预定义的诊断类别。相反，该系统将患者问题作为自由文本记录存储在数据库中。随后的诊断分类和编码通过提示的自由文本输入和适当的参考数据库来完成。这种系统设计允许门诊问题列表摘要除了反映编码的医学诊断外，还能反映非分类的健康状况信息。

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