Moran W P, Messick C, Guerette P, Anderson R, Bradham D, Wofford J L, Velez R
Department of Internal Medicine, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina.
Proc Annu Symp Comput Appl Med Care. 1994:585-9.
Primary care physicians provide longitudinal care for chronically ill individuals in concert with many other community-based disciplines. The care management of these individuals requires data not traditionally collected during the care of well, or acutely ill individuals. These data not only concern the patient, in the form of patient functional status, mental status and affect, but also pertain to the caregiver, home environment, and the formal community health and social service system. The goal of the Community Care Coordination Network is to build a primary care-based information system to share patient data and communicate patient related information among the community-based multi-disciplinary teams. One objective of the Community Care Coordination Network is to create a Community Care Database for chronically ill individuals by identifying those data elements necessary for efficient multi-disciplinary care.
基层医疗医生与许多其他社区学科共同为慢性病患者提供长期护理。对这些患者的护理管理需要一些在健康个体或急性病患者护理过程中传统上不会收集的数据。这些数据不仅涉及患者，包括患者的功能状态、精神状态和情感等形式，还涉及护理人员、家庭环境以及正式的社区健康和社会服务系统。社区护理协调网络的目标是建立一个基于基层医疗的信息系统，以共享患者数据并在社区多学科团队之间交流与患者相关的信息。社区护理协调网络的一个目标是通过确定高效多学科护理所需的数据元素，为慢性病患者创建一个社区护理数据库。
