Hospital outpatient medical summary.

H K Mak
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Abstract

The rationale for having a hospital outpatient summary is discussed. A design is proposed which is complementary to a priorly proposed inpatient-episode summary aiming at speedy information retrieval while providing for efficient referencing. It has the following features: It records chronologically the essentials of the evolving health status and its management in the outpatient mode. It is especially formatted to accommodate the multispecialty orientation in the outpatient setting. It registers the evolution of previous diagnoses and health problems to give a clear background picture of prior health status. There is flexibility to allow for editing and arbitrary cut-offs for special situations. It is simple and easy to implement. It is computer compatible.

医院门诊病历汇总。
讨论了医院门诊总结的基本原理。提出了一种补充先前提出的住院患者事件摘要的设计,旨在快速检索信息,同时提供有效的参考。它具有以下特点:它按时间顺序记录了门诊模式下不断变化的健康状况及其管理的要点。它是特别格式化,以适应多专业方向在门诊设置。它记录了以前的诊断和健康问题的演变,以提供以前健康状况的清晰背景情况。有灵活性,允许编辑和任意切断特殊情况。它简单且易于实现。它是电脑兼容的。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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