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[既往史与临床检查]

[Anamnesis and clinical examination].

作者信息

Grüne Stefan

出版信息

Dtsch Med Wochenschr. 2016 Jan;141(1):24-7. doi: 10.1055/s-0041-106337. Epub 2015 Dec 28.

Abstract

Anamnesis and clinical examination are the key functions of medical doctors to reveal the health problems of their patients. The correct assessment and handoff of these informations are the preconditions for a specific and cost saving diagnostic and therapy. The handoff can be made orally, in written form analogue or digital. The examination and documentation should be conducted in the order specified for every patient to avoid mistakes. New digital programs help to reach this aim but absorb the time of the medical doctor and depart him from the patients. Nurses and medical doctors should perform the rounds together for a mutually acquisition of information. This conduces towards a single-minded and cost-effectively diagnostic and therapy.

摘要

病史采集和临床检查是医生发现患者健康问题的关键职能。对这些信息进行正确评估和交接是进行针对性且节省成本的诊断和治疗的前提条件。交接可以通过口头、纸质或数字形式进行。应按照为每位患者规定的顺序进行检查和记录,以避免出错。新的数字程序有助于实现这一目标,但会占用医生的时间,使他们无法专注于患者。护士和医生应共同查房以相互获取信息。这有助于实现统一且经济高效的诊断和治疗。

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