Leiner F, Haux R
Department of Medical Informatics, University of Goettingen, Germany.
Methods Inf Med. 1996 Mar;35(1):25-34.
All information obtained from a patient in the course of medical care is a potential part of clinical documentation. The documentation usually serves a number of different purposes. The task of a documentation system is to fulfil these purposes in a methodically correct manner and as economically as possible. This requires that the properties of the documentation system be planned systematically with a view to the goals pursued. To support systematic planning, a "documentation protocol" is proposed analogous to the "study protocol" used for controlled clinical trials. The individual sections of the proposed documentation protocol are described and the design options which exist in the corresponding planning phases are pointed out. Experience gained by the application of the documentation protocol is discussed.
在医疗护理过程中从患者那里获得的所有信息都是临床文档的潜在组成部分。该文档通常服务于许多不同的目的。文档系统的任务是以有条不紊且正确的方式并尽可能经济地实现这些目的。这就要求根据所追求的目标对文档系统的属性进行系统规划。为支持系统规划，类似于用于对照临床试验的“研究方案”，提出了一种“文档方案”。描述了所提议文档方案的各个部分，并指出了相应规划阶段中存在的设计选项。讨论了应用文档方案所获得的经验。
