首页> 美国卫生研究院文献>AMIA Annual Symposium Proceedings >III. the Physicians Office and Group Practice—Ambulatory Medical Record Systems: A. Automated Medical Record Systems: Development of a Computer-Assisted Problem-Oriented Medical Record System for Office Use
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III. the Physicians Office and Group Practice—Ambulatory Medical Record Systems: A. Automated Medical Record Systems: Development of a Computer-Assisted Problem-Oriented Medical Record System for Office Use

机译:三医生的办公室和团体执业—病历系统:A.自动化的病历系统:开发用于办公室的计算机辅助的以问题为导向的病历系统

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摘要

Development of a computer-assisted problem-oriented medical record system in a small group practice setting is described. The patient data base includes: problem list with assessments, medication list, drug allergies, chronologic past history and minor illness summary. Methods developed for entering and maintaining the data base are described, as well as a coding system for problems, drugs and procedures which will allow information retrieval. Initial results suggest the feasibility of a computer-assisted medical record in office practice with potential advantages for the physician in reduction of paper work.
机译:描述了在小组练习环境中以计算机辅助的面向问题的病历系统的开发。患者数据库包括:带有评估的问题列表,药物清单,药物过敏,按时间顺序的既往史和轻微疾病摘要。描述了为输入和维护数据库而开发的方法,以及用于问题,药物和程序的编码系统,这些系统将允许检索信息。初步结果表明,在办公室实践中使用计算机辅助医疗记录的可行性对医生减少文书工作具有潜在优势。

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