Benson D S, Van Osdol W, Townes P
Ambulatory Care Services, Methodist Hospital of Indiana, Inc., Indianapolis 46206.
QRB Qual Rev Bull. 1988 Jun;14(6):192-7. doi: 10.1016/s0097-5990(16)30214-7.
In ambulatory health care, patient records are important for assuring continuity of care. The diagnostic summary, or problem list, and the medication record are particularly useful for providing an overview of patients' significant diagnoses and treatments. If well-structured, reliable, and consistent, they can also contribute substantially to the quality of patient care.
在门诊医疗中,患者记录对于确保护理的连续性至关重要。诊断摘要或问题清单以及用药记录对于提供患者重要诊断和治疗的概述特别有用。如果结构良好、可靠且一致,它们也可以对患者护理质量做出重大贡献。