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以问题为导向的病历记录:综述

Problem-oriented charting: A review.

作者信息

Chowdhry Shilpa M, Mishuris Rebecca G, Mann Devin

机构信息

Department of Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, United States.

Department of Medicine. Boston University School of Medicine, United States.

出版信息

Int J Med Inform. 2017 Jul;103:95-102. doi: 10.1016/j.ijmedinf.2017.04.016. Epub 2017 Apr 29.

Abstract

Problem-oriented charting is form of medical documentation that organizes patient data by a diagnosis or problem. In this review, we discuss the history and current use of problem-oriented charting by critically evaluating the literature on the topic. We provide insights with regard to our own institutional use of problem-oriented charting and potential opportunities for research.

摘要

问题导向型病历记录是一种医疗文档形式,它通过诊断或问题来组织患者数据。在本综述中,我们通过批判性地评估该主题的文献来讨论问题导向型病历记录的历史和当前应用。我们提供了关于我们自己机构对问题导向型病历记录的使用情况以及潜在研究机会的见解。

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