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ASOP:一种用于记录临床会诊的新方法和工具。

ASOP: a new method and tools for capturing a clinical encounter.

作者信息

Gensinger R A, Fowler J

机构信息

SIU School of Medicine, Springfield, Illinois, USA.

出版信息

Proc Annu Symp Comput Appl Med Care. 1995:142-6.

Abstract

ASOP is a proposed method for future medical record notation. This permutation of the original POMR-SOAP method is necessary to provide the standardized workflow and medical nomenclature which will be essential for automated medical record systems and forms-based encounter recording. The development of an ASOP system is dependent on tools to map assessment to appropriate terminology within a universal medical dictionary and generate intelligent queries across the World-Wide-Web. In this study we intend to demonstrate the need for change in the POMR system and highlight some of the current tools in development to make the ASOP method the medical record notation system of choice.

摘要

ASOP是一种针对未来病历记录提出的方法。对原始POMR - SOAP方法进行这种排列对于提供标准化工作流程和医学术语至关重要,这对于自动化病历系统和基于表单的会诊记录而言必不可少。ASOP系统的开发依赖于一些工具,这些工具能够将评估映射到通用医学词典中的适当术语,并在万维网上生成智能查询。在本研究中,我们打算证明POMR系统需要变革,并重点介绍一些目前正在开发的工具,以使ASOP方法成为首选的病历记录系统。

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