Given C W, Simoni L, Gallin R S, Sprafka R J
J Fam Pract. 1977 Nov;5(5):831-40.
This paper describes the way in which data from a computer-based health information system are used to review the service experiences of family practice residents. First, it discusses the development of the patient profiles that provide a chronological account of a patient's visits, their purposes, diagnoses, laboratory procedures, treatments, and outcomes. Then, through four cases, it describes the way in which these computer-generated displays are used by faculty to conduct concurrent reviews of residents' performances, to select medical records for review, and to initiate feedback and instruction to residents as they care for their patients.
本文描述了利用基于计算机的健康信息系统中的数据来评估家庭医疗住院医生服务体验的方式。首先,讨论了患者档案的建立,这些档案按时间顺序记录了患者的就诊情况、就诊目的、诊断、实验室检查、治疗及结果。然后,通过四个案例,描述了教员如何利用这些计算机生成的显示内容对住院医生的表现进行同步评估、选择病历进行审查,以及在住院医生照顾患者时向他们提供反馈和指导。