Suppr超能文献

向患者提供其计算机病历的副本。

Giving patients a copy of their computer medical record.

作者信息

Sheldon M G

出版信息

J R Coll Gen Pract. 1982 Feb;32(235):80-6.

Abstract

Medical summaries were prepared by a general practitioner for inclusion in a computer system. Both the medical records and a patient-filled questionnaire were used. A representative sample of the practice population were then sent their summaries. In creating the summaries the general practitioner felt the need to exclude 11 diagnoses whenever they appeared (5 per cent of the patients), and to suppress one or more diagnoses in a further 14 per cent of patients. In 2 per cent of summaries the general practitioner felt unable to give a copy to the patient because he was afraid of an adverse reaction by the patient or immediate relatives.The patients' views of the usefulness of the summaries, and of their accuracy and completeness, were sought by a questionnaire. Replies were received from 71 per cent; of these, 91 per cent reported that they thought the summary useful. However, in 18 per cent of cases, the patients requested additions, corrections or deletions. Only 1 per cent of patients replied that they definitely did not like the idea of a computer containing their medical information.Some of the benefits and difficulties both of using a computer to store medical information, and of giving the patient a copy of the medical summary, are discussed.

摘要

全科医生编写了医学摘要以纳入计算机系统。他们使用了病历和患者填写的问卷。然后,向该诊所患者群体的一个代表性样本发送了他们的摘要。在编写摘要时,全科医生觉得有必要在每次出现时排除11种诊断(占患者的5%),并在另外14%的患者中隐瞒一种或多种诊断。在2%的摘要中,全科医生觉得无法给患者一份,因为他担心患者或其直系亲属会有不良反应。通过问卷调查了解患者对摘要有用性、准确性和完整性的看法。收到了71%的回复;其中,91%的人报告说他们认为摘要有用。然而,在18%的情况下,患者要求补充、更正或删除内容。只有1%的患者回复说他们绝对不喜欢计算机存储其医疗信息的想法。本文讨论了使用计算机存储医疗信息以及给患者一份医学摘要的一些好处和困难。

相似文献

引用本文的文献

2
Patient-initiated electronic health record amendment requests.患者发起的电子健康记录修正请求。
J Am Med Inform Assoc. 2014 Nov-Dec;21(6):992-1000. doi: 10.1136/amiajnl-2013-002574. Epub 2014 May 26.

文献检索

告别复杂PubMed语法,用中文像聊天一样搜索,搜遍4000万医学文献。AI智能推荐,让科研检索更轻松。

立即免费搜索

文件翻译

保留排版,准确专业,支持PDF/Word/PPT等文件格式,支持 12+语言互译。

免费翻译文档

深度研究

AI帮你快速写综述,25分钟生成高质量综述,智能提取关键信息,辅助科研写作。

立即免费体验