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[手部手术中以清晰文本为导向的文档记录——整合于医疗常规文档服务中]

[Clear text-oriented documentation in hand surgery--integrated in the medical routine documentation service].

作者信息

Salm R, Goth D, Bodendorf F

出版信息

Handchir Mikrochir Plast Chir. 1986 Mar;18(2):86-9.

PMID:3754531
Abstract

For reasons of contents and economy, the construction of medical documentation should be integrated into the secretary's routine work. An efficient and inexpensive microcomputer is able to facilitate and accelerate the typing work of a hand surgical section by the use of a modern data processing system. At the same time important data can be stored for documentation without being coded and with hardly any additional effort. The dates can be analysed according to different criteria (e.g. statistics of diagnosis/therapy, the recall of data of patients with certain diagnosis, yearly statistics and so on). Knowledge of data processing is not necessary.

摘要

出于内容和经济方面的考虑,医疗文档的构建应融入秘书的日常工作。一台高效且价格低廉的微型计算机能够通过使用现代数据处理系统,促进和加快手外科科室的打字工作。与此同时,重要数据无需编码且几乎无需额外努力即可存储用于文档记录。数据可根据不同标准进行分析(例如诊断/治疗统计、特定诊断患者数据的检索、年度统计等)。无需具备数据处理知识。

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