Lapochkin V I, Kudriavtsev V S, Svirin A V
Department of Eye Diseases, Russian State Medical University, Moscow.
Vestn Oftalmol. 1997 Mar-Apr;113(2):32-4.
The authors present the fundamentals of making outpatient computer case histories for prophylactic check-ups of chronic outpatients with ocular diseases. They validate the necessity of creating mononosological versions of computer histories which should not only describe the underlying diseases in detail, but reflect any concomitant ocular disease as well. The basic criteria formulated by the authors helped create a computer history of a modulus type, which may be easily mastered by physicians within just 2-3 hours and be adapted to research of this or that patient population. The authors emphasize the importance of creating and wide use of software in everyday practical medicine.
作者介绍了为患有眼部疾病的慢性门诊患者进行预防性检查制作门诊计算机病历的基本原理。他们验证了创建单一病种版本计算机病历的必要性,这种病历不仅应详细描述基础疾病,还应反映任何伴发的眼部疾病。作者制定的基本标准有助于创建一种模块式的计算机病历,医生只需2至3小时就能轻松掌握,并且可适用于对不同患者群体的研究。作者强调了在日常实际医疗中创建和广泛使用软件的重要性。