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错误信息时代:病历的衰落。

The misinformation era: the fall of the medical record.

作者信息

Burnum J F

出版信息

Ann Intern Med. 1989 Mar 15;110(6):482-4. doi: 10.7326/0003-4819-110-6-482.

Abstract

Medical record information has become less reliable than ever before despite the electronic information revolution in medical care and the authority medical records have been accorded in our society. Long flawed by errors introduced by medical personnel, patients, and machines, medical records have had a further decline in credibility as a result of the loss of confidentiality and the imposition of well-meaning but unrealistic cost-control regulations on medical practice. Medical records are being distorted and fashioned to keep clinically important but sensitive personal information about patients from public view. To comply with standards of care and a reimbursement system blind to biologic diversity, medical records are being forced to address only the technical side of care. Until these deficiencies are corrected, our increasing dependence on medical records should be balanced by increasing skepticism about the value of the information they contain.

摘要

尽管医疗保健领域发生了电子信息革命,且病历在我们社会中享有权威性,但病历信息却比以往任何时候都更不可靠。长期以来,病历因医务人员、患者和机器引入的错误而存在缺陷,如今又因保密性的丧失以及对医疗实践实施的善意却不切实际的成本控制规定,其可信度进一步下降。病历正被扭曲和塑造,以防止有关患者的具有临床重要性但敏感的个人信息被公众看到。为了符合护理标准和一个对生物多样性视而不见的报销系统,病历被迫只关注护理的技术层面。在这些缺陷得到纠正之前,我们对病历日益增加的依赖,应该通过对病历所含信息价值的日益怀疑来加以平衡。

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