Lovrić D, Negovetić L, Lupret V
Lijec Vjesn. 1989 Jun-Jul;111(6-7):232-5.
Actual medical recording shows to be inadequate for daily use as well as for computer elaboration. The problem oriented medical records are being used worldwide. They consist of a problem list, data base, initial plan and course of cure. All the parts need to be acceded permanently and in the proper way. Computer elaboration of data enables the physical diminution and easier understanding of immense amount of data, especially if the input mode differs from the output one. The same relevance have what- and where-factors for any moment of usage. That depends on medical processing, so this article treats the problem of medical recording at a typical Department of Surgery.
实际的医疗记录显示,无论是日常使用还是计算机处理都存在不足。面向问题的医疗记录正在全球范围内使用。它们由问题列表、数据库、初始计划和治疗过程组成。所有这些部分都需要以适当的方式永久保存。数据的计算机处理能够减少实体记录并更轻松地理解大量数据,特别是当输入模式与输出模式不同时。在任何使用时刻,“什么”和“哪里”因素都具有同样的相关性。这取决于医疗处理过程,因此本文探讨了典型外科科室的医疗记录问题。