患者预防措施：电子病历中被遗忘的一部分。
Patient precautions: a forgotten piece of the electronic patient record.
作者信息
Sands D Z, Safran C
机构信息
Division of Clinical Computing, Beth Israel Hospital, Boston, MA, USA.
出版信息
Proc Annu Symp Comput Appl Med Care. 1995:77-80.
We define "patient precautions" as a unique group of data that is an essential component of the electronic patient record. Patient precautions include medication allergies, difficult airway precautions, infection control precautions, and advance directives. Any piece of data that is associated with the patient, can affect the management of his or her care, and is relatively static over time (as compared with the patient's medication list and problem list) can be considered a patient precaution. An important property of precautions is that the relevant aspects may be brought to the user's attention at the time a patient care decision must be made. We believe this class of data elements is a unique and important component of the electronic patient record that makes it more valuable than the paper record.
我们将“患者预防措施”定义为一组独特的数据，它是电子病历的重要组成部分。患者预防措施包括药物过敏、困难气道预防措施、感染控制预防措施和预先医疗指示。任何与患者相关、可能影响其治疗管理且随时间相对稳定的数据（与患者的用药清单和问题清单相比）都可被视为患者预防措施。预防措施的一个重要特性是，在必须做出患者护理决策时，相关方面可能会引起用户的注意。我们认为这类数据元素是电子病历中独特且重要的组成部分，使其比纸质病历更具价值。
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