摘要
准确、一致、完整、及时的临床信息对医生解决患者的健康问题大有裨益。临床事件总结在适当的详细程度和完整性上提供信息,使医生迅速捕获与服务对象健康相关的信息,可提高医疗质量和工作效率。本文以出院总结为例,对临床事件总结的规范化进行了探讨。
Accurate, consistent, complete and timely information are very helpful for doctors to solve patients＇ health problems. Each healthcare event provides plenty of information on a consumer＇s or a patient＇s health. Clinical event summaries can help chnicians involved capture useful information of service targets rapidly, to improve health care quality and efficiency. In this paper, standardization of hospital discharge summary is studied.
出处
《中国全科医学》
CAS
CSCD
2008年第14期1316-1317,共2页
Chinese General Practice
关键词
医学信息学
病案
临床事件总结
出院总结
Medical informatics
Medical Records
Clinical event summary
Hospital discharge summary
