Zonov P
Sante Publique (Bucur). 1990 Jan-Mar;33(1):3-10.
The paper reports on the general and specific functions of medical records, as well as on the need to improve medical recording and the circulation of medical records in health units. The economic medical and social advantages of keeping accurate records are highlighted. Recent breakthroughs in information science permit unifying and standardizing medical records, making them more problem-oriented, developing technical equipment and extending its use in archives, expanding the role of the computer in clinical recording.
该论文报告了病历的一般和特定功能,以及改进医疗记录和健康单位中病历流通的必要性。强调了保存准确记录在经济、医疗和社会方面的优势。信息科学的最新突破使得病历能够统一和标准化,使其更具问题导向性,开发技术设备并扩大其在档案中的应用,扩大计算机在临床记录中的作用。