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[综合内科护理过程中的文件记录]

[Documentation in the polyclinic-internal medicine care process].

作者信息

Wenzel K P

出版信息

Z Gesamte Inn Med. 1985 Apr 15;40(8):241-2.

PMID:4013441
Abstract

In five full-time and part-time specialists for internal medicine, respectively, of the district outpatient department the quality of the documentation of the ambulatory care has been tested. The documentations proved to be sufficient. Obviously this or that specialist sometimes keeps away from establishing a tentative diagnosis in the primary consultation. But the making of a preliminary diagnosis involves to do with a limited but sufficient examination programme.

摘要

在该地区门诊部的五名全职和兼职内科专家中,分别对门诊护理的文档质量进行了测试。测试结果表明文档是充分的。显然,某些专家有时在初次会诊时不进行初步诊断。但做出初步诊断只需进行有限但充分的检查程序。

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