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全科医疗中的病历。艺术与科学的交汇之处。

The medical record in general practice. Where art and science meet.

作者信息

Sigurdsson G

出版信息

Scand J Prim Health Care. 1984 Sep;2(3):113-6. doi: 10.3109/02813438409018084.

Abstract

The human relationship between healer and patient constitutes the basis of medical practice. It has been customary for health professionals to make a written record of their observations on the interaction. The efforts to produce better records consist of structuring them more clearly and extracting certain items of information in order to be able to index them like books in a library. The electronic computer can solve some of these problems but general practitioners have to be aware of the limitations of the computer.

摘要

治疗者与患者之间的人际关系构成了医疗实践的基础。健康专业人员习惯对他们关于互动的观察做书面记录。为了能像图书馆里的书籍那样为记录编制索引,努力制作更好的记录包括更清晰地组织记录以及提取某些信息项。电子计算机可以解决其中一些问题,但全科医生必须意识到计算机的局限性。

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