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[一种面向全科医生的实用临床记录系统]

[A practical clinical record system for the general practitioner].

作者信息

Pistorius G J

出版信息

S Afr Med J. 1979 Jun 30;55(27):1119-24.

PMID:314675
Abstract

Owing to the multidisciplinary character of general practice, there is a great need for an effective and practical clinical record system for the family physician. The recording of clinical data of home visits and other visits places an extra burden on his record system. A practical system which tries to solve these and other problems is presented. A simplified form of Weed's Problem Orientated Medical Records (POMR) is incorporated in this system. The different components as well as the practical functioning of the system are described.

摘要

由于全科医疗的多学科性质,家庭医生迫切需要一个有效且实用的临床记录系统。家访和其他诊疗的临床数据记录给其记录系统带来了额外负担。本文介绍了一个试图解决这些及其他问题的实用系统。该系统纳入了简化版的威德问题导向型医疗记录(POMR)。文中描述了该系统的不同组成部分及其实际运行情况。

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