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Developing an Electronic Record Tool Representative of Primary Health Care in the Public Health Care System of Buenos Aires City

机译：在布宜诺斯艾利斯市公共医疗保健系统中制定电子记录工具代表初级医疗保健系统

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The Primary Health Care strategy is based on organization of interdisciplinary teams and comprehensive approach to health, disease and health care processes. To strengthen information systems so that they represent primary health care complexities, participatory meetings were held with primary care practitioners from the public health care system of Buenos Aires City. Terms for the record tool and its components were chosen using consensus methodologies. This process involved 300 practitioners from 49 centers, and submission of 21 proposals. It was decided to change the term “Electronic Medical Record” with “Comprehensive Health Record.” It was also agreed that, apart from “Reason for Consultation,” the field “Problem Situation” would be added, that “Care Service” would be replaced with “Care Act,” and that a new module “Health Team Management and Education Activities” would be included to document practitioners team activities.
机译：主要医疗战略基于组织跨学科团队和卫生，疾病和医疗保健过程的综合方法。 为了加强信息系统，使他们代表初级保健复杂性，参与式会议与布宜诺斯艾利斯市公共卫生制度的初级护理从业人员举行。 使用共识方法选择记录工具及其组件的术语。 此过程涉及49个中心的300名从业者，并提交21个提案。 决定改变“电子医疗记录”一词，“综合健康记录”。 还有人同意，除了“咨询原因”之外，将补充“问题情况”，即“护理服务”将被“护理法”所取代，并将新的模块“卫生团队管理和教育活动取代 “将包含在文件从业者团队活动中。

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