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问题导向型医疗记录——全有或全无?

Problem orientated medical records--all or none?

作者信息

Antoniou A G, Sever E D, Toby J P

出版信息

Med Educ. 1979 May;13(3):217-8. doi: 10.1111/j.1365-2923.1979.tb01444.x.

Abstract

Junior hospital doctors from different medical schools were asked about their experience of the Problem Orientated Medical Record. Few had been introduced to this method of writing notes by their teachers when they were undergraduates, though more had learned about it from other sources. The majority of those with experience of the method found it preferable to the more conventional one. The advantages and disadvantages of the method are discussed and it is suggested that a less rigid format might make it more acceptable. This can be achieved by writing follow-up notes in the usual way and using the problem orientated approach only when the patient is assessed for the first time or when information is passed from one team of doctors to another.

摘要

来自不同医学院的实习医生被问及他们对问题导向医疗记录的体验。很少有人在本科时由老师介绍过这种记录方法,不过更多人是从其他渠道了解到的。大多数有该方法使用经验的人认为它比传统方法更可取。文中讨论了该方法的优缺点,并建议采用不那么严格的格式可能会使其更容易被接受。这可以通过按常规方式书写随访记录来实现,仅在首次评估患者或医生团队之间传递信息时使用问题导向方法。

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