Wyatt J C, Wright P
School of Public Policy, University College London, UK.
Lancet. 1998 Oct 24;352(9137):1375-8. doi: 10.1016/S0140-6736(97)08306-2.
Checklists and other tools help doctors to use published evidence in clinical practice. Two other important sources of evidence, however, are the patient and his or her medical record. This series aims to advance the practice of evidence-based medicine by helping in redesign of medical records, drawing on insights from psychology, information design, and medical informatics; and by promoting changes analogous to those occurring in the medical literature. The four papers look at: the uses of medical records and importance of organising them so doctors can use the data they contain; different methods doctors use to search for data and how design of records can help or hinder these approaches; how we interpret data once found, and how record formatting assists this process; and the issues raised by computerisation of records.
检查表及其他工具可帮助医生在临床实践中运用已发表的证据。然而,另外两个重要的证据来源是患者及其病历。本系列旨在通过借鉴心理学、信息设计和医学信息学的见解,助力重新设计病历,从而推动循证医学的实践;并促进类似于医学文献中所发生的变革。这四篇论文探讨了:病历的用途以及整理病历的重要性,以便医生能够使用其中包含的数据;医生用于搜索数据的不同方法,以及病历设计如何有助于或阻碍这些方法;我们一旦找到数据后如何进行解读,以及病历格式如何辅助这一过程;以及病历计算机化所引发的问题。