Wasserman Richard C
Professor Emeritus of Pediatrics, Larner College of Medicine, University of Vermont, USA.
Curr Probl Pediatr Adolesc Health Care. 2022 Jan;52(1):101108. doi: 10.1016/j.cppeds.2021.101108. Epub 2021 Dec 10.
Medical documentation arose as individual case reports written for teaching purposes. Documentation for patient care later occurred in physicians' personal daybooks and only evolved into the individual patient record in the early 20th century. Dr. Lawrence Weed improved the utility of the patient record by introducing a problem-oriented/subject-object-assessment-plan structure and he and other innovators transformed the patient record into electronic form. Pediatricians built on these innovations to create a child health electronic health record (EHR) for primary care. An American Academy of Pediatrics task force formally specified the child-specific needs of the EHR, but much work remains to integrate the EHR into the pediatric primary care of the future.
医学文档最初是为教学目的编写的个体病例报告。后来,用于患者护理的文档出现在医生的个人日志中,直到20世纪初才演变成个体患者记录。劳伦斯·威德博士通过引入问题导向/主题-对象-评估-计划结构提高了患者记录的实用性,他和其他创新者将患者记录转变为电子形式。儿科医生在这些创新的基础上,为初级保健创建了儿童健康电子健康记录(EHR)。美国儿科学会的一个特别工作组正式明确了EHR针对儿童的特定需求,但要将EHR整合到未来的儿科初级保健中仍有许多工作要做。