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概要记录卡:通向计算机的垫脚石。

The synopsis record card: a stepping stone to the computer.

作者信息

Preece J F, Hearson J R

出版信息

J R Coll Gen Pract. 1986 Dec;36(293):564-6.

Abstract

A synopsis record card has been developed for use in general practice to provide ready reference to the important facts of the patient's record. When such a card is available in the record wallet it is used at 50% of all patient consultations and significantly reduces the time needed to retrieve past data essential to the consultation. The card contains clinical details, and data on medication, drug idiosyncrasies, immunizations, screening procedures, social, occupational and family history and practice research. As synopsis records are particularly important in teaching practices and when referral letters to hospital or personal medical attendant insurance reports are written, provision has been made for the inclusion of data relevant to those functions. So that the card may act as an intermediary for record computerization, all elements needed in the construction of a computer record have been taken into account. The prototype card was circulated to 3000 RCGP members for comment and the majority of replies were favourable. Suggested modifications have been incorporated in the final design of the card.

摘要

已开发出一种概要记录卡,用于全科医疗,以便随时查阅患者记录的重要信息。当记录夹中有这样一张卡片时,在所有患者会诊中50%的情况下都会使用它,并且显著减少了检索会诊所需过往数据的时间。该卡片包含临床细节、用药数据、药物过敏情况、免疫接种、筛查程序、社会、职业和家族病史以及实践研究等信息。由于概要记录在教学实践以及撰写给医院的转诊信或个人医疗护理保险报告时尤为重要,因此已考虑纳入与这些功能相关的数据。为使该卡片能够作为记录计算机化的中介,构建计算机记录所需的所有要素都已被考虑在内。该原型卡已分发给3000名皇家全科医师学院成员征求意见,大多数回复都是积极的。建议的修改已纳入卡片的最终设计中。

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