Weinstein P, Gordon M J, Gilson J S
West J Med. 1977 Apr;126(4):324-9.
Effective methods developed to review and study the care of patients in hospital have not been applicable to ambulatory care, in which definitive diagnosis is the exception rather than the rule. A reasonable alternative to using diagnosis as the basis for assessing ambulatory care is to use the problems or requests presented by the patients themselves. A system has been developed for classifying and coding this information for flexible computer retrieval. Testing indicates that the system is simple in design, easily mastered by nonphysicians and provides reliable, useful data at a low cost.
为审查和研究住院患者护理而开发的有效方法并不适用于门诊护理,在门诊护理中,明确诊断是例外而非惯例。一种合理的替代方法是,不将诊断作为评估门诊护理的基础,而是使用患者自身提出的问题或请求。现已开发出一种系统,用于对这些信息进行分类和编码,以便灵活地进行计算机检索。测试表明,该系统设计简单,非医生人员易于掌握,并且能以低成本提供可靠、有用的数据。