Bishop C W
Department of Medicine, Erie County Medical Center, Buffalo, NY 14215.
MD Comput. 1991 Jul-Aug;8(4):208-15.
Over the centuries, the medical record has become stereotyped. Reconsidering the purpose and organization of this document leads me to propose a four-part format consisting of administrative data, a patient synopsis, a chronological medical record, and a detailed medical record. The patient would be identified only in the administrative data section, leaving the rest of the record available for management, outcome, and cost studies, and protecting the patient's privacy. Adoption of this four-part format would make it easier to locate information in the medical record and would facilitate computerization. If the phraseology could be standardized, the new format would also allow easier data flow from one medical record to another and permit the construction of standardized disease profiles. Data on individual patients could then be compared with standardized profiles to identify deficiencies and redundancies in patient care.
几个世纪以来，病历已变得千篇一律。重新思考这份文件的目的和结构，促使我提出一种由四部分组成的格式，包括管理数据、患者概要、按时间顺序排列的病历和详细病历。患者仅在管理数据部分被识别，其余病历可供管理、结果和成本研究使用，并保护患者隐私。采用这种四部分格式将使在病历中查找信息更加容易，并便于计算机化。如果措辞能够标准化，新格式还将使数据在不同病历之间的流动更加顺畅，并允许构建标准化的疾病档案。然后，可以将个体患者的数据与标准化档案进行比较，以识别患者护理中的不足和冗余之处。
