Bernstein S
J R Army Med Corps. 1983 Jun;129(2):66-8. doi: 10.1136/jramc-129-02-02.
Problem orientated medical records will accommodate and integrate information about minor and major problems, allow rapid updating of information and better communication between health agencies and primary care team members. They will allow colleagues to retrieve information and assess patient problems, enable better co-ordination to occur between patient investigation and treatment, and rationalise decision making. In Part Two a method of medical recording is described using various coloured forms. Problems encountered and suggested solutions have been made. It is felt that the introduction of this method will lead to improved medical care for patients.
问题导向型医疗记录将收纳并整合有关轻重问题的信息,实现信息的快速更新以及卫生机构与基层医疗团队成员之间的更好沟通。它们将使同事能够检索信息并评估患者问题,促进患者检查与治疗之间更好地协调,并使决策更加合理。在第二部分中,描述了一种使用各种颜色表格的医疗记录方法。还提出了遇到的问题及建议的解决方案。人们认为采用这种方法将改善对患者的医疗护理。