一种捕捉关于患者问题的临床推理的数据模型。
A data model that captures clinical reasoning about patient problems.
作者信息
Barrows R C, Johnson S B
机构信息
Department of Medical Informatics, Columbia University, New York, NY, USA.
出版信息
Proc Annu Symp Comput Appl Med Care. 1995:402-5.
We describe a data model that has been implemented for the CPMC Ambulatory Care System, and exemplify its function for patient problems. The model captures some nuances of clinical thinking about patients that are not accommodated in most other models, such as an evolution of clinical understanding about patient problems. A record of this understanding has clinical utility, and serves research interests as well as medical audit concerns. The model is described with an example, and advantages and limitations in the current implementation are discussed.
我们描述了一种已在加州太平洋医疗中心门诊护理系统中实现的数据模型，并举例说明了其在患者问题方面的功能。该模型捕捉到了大多数其他模型未涵盖的一些临床对患者思考的细微差别，比如对患者问题临床理解的演变。这种理解的记录具有临床实用性，既服务于研究兴趣，也关乎医疗审计问题。通过一个例子对该模型进行了描述，并讨论了当前实现中的优点和局限性。
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