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1
Giving patients a copy of their computer medical record.向患者提供其计算机病历的副本。
J R Coll Gen Pract. 1982 Feb;32(235):80-6.
2
Computers in general practice: the patient's voice.全科医疗中的计算机:患者的声音。
J R Coll Gen Pract. 1981 Nov;31(232):683-5.
3
Attitudes towards, and utility of, an integrated medical-dental patient-held record in primary care.基层医疗中对综合医疗-牙科患者病历的态度及实用性
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The completeness and accuracy of patient record transfer between practices.医疗机构之间患者记录转移的完整性和准确性。
Health Bull (Edinb). 1997 Jan;55(1):16-9.
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Electronic medical summaries in general practice--considering the patient's contribution.全科医疗中的电子病历摘要——考虑患者的贡献
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Epilepsy monitoring and advice recorded: general practitioners' views, current practice and patients' preferences.癫痫监测与建议记录:全科医生的观点、当前实践及患者偏好
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[Should patients in general practice be offered a copy of their medical record?].[在全科医疗中应向患者提供其病历副本吗?]
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Patient on-line access to medical records in general practice.患者在线获取全科医疗中的病历记录。
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Censoring of patient-held records by doctors.医生对患者保存记录的审查。
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Surgical discharge summaries: improving the record.手术出院小结:完善记录。
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Patient-initiated electronic health record amendment requests.患者发起的电子健康记录修正请求。
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The impact of electronic patient portals on patient care: a systematic review of controlled trials.电子患者门户对患者护理的影响:对照试验的系统评价
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The effects of promoting patient access to medical records: a review.促进患者获取病历的效果:一项综述。
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6
Attitudes towards, and utility of, an integrated medical-dental patient-held record in primary care.基层医疗中对综合医疗-牙科患者病历的态度及实用性
Br J Gen Pract. 1999 May;49(442):368-73.
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8
A computer generated patient carried health check card.一张电脑生成的患者健康检查卡。
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9
Censoring of patient-held records by doctors.医生对患者保存记录的审查。
J R Coll Gen Pract. 1988 Mar;38(308):117-8.
10
Medical records: practicalities and principles of patient possession.医疗记录:患者持有记录的实际情况与原则
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本文引用的文献

1
Confidentiality and medical records.保密性与医疗记录。
J R Coll Gen Pract. 1978 Mar;28(188):137-40.
2
Self-audit of prescribing habits and clinical care in general practice.一般诊疗中医嘱开具习惯及临床护理的自我审核
J R Coll Gen Pract. 1979 Dec;29(209):703-6, 710-1.
3
Medical records and medical information in the U.K.--issues and prospects.英国的医疗记录与医疗信息——问题与前景
Public Health. 1979 Sep;93(5):290-9. doi: 10.1016/s0033-3506(79)80080-3.

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.

PMID:7097630
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC1971001/
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。