Peris R, Colomer J, Terrada M L, Brines J, Borrajo E
An Esp Pediatr. 1977 Nov;10(11):785-800.
The object of this paper is the presentation of the problem griented medical record now in use at the Department of Pediatrics of the Faculty of Medicine of the University of Valencia. The main documents of this medical record (problem list, discharge summary, anamnesis and physical examination summary, and medical record summary) are given describing the characteristics of format and the rules for its completion. The relationships between the main documents are shown.
本文的目的是介绍目前瓦伦西亚大学医学院儿科学系正在使用的问题导向型病历。给出了该病历的主要文件（问题清单、出院小结、病史和体格检查小结以及病历摘要），描述了格式特点及其填写规则。展示了主要文件之间的关系。
