[计算机化病历:从迷失的幻想到复兴的希望]。

Revue medicale de Liege Pub Date : 2024-09-01
Philippe Coucke
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引用次数: 0

摘要

尽管记录和传输病人数据的原则并不新鲜,但当今护理实践中使用的计算机化病历仍不能满足需要。我们可以轻易地--而且往往是正确地--对这些医疗记录的设计者和医疗机构的管理者进行指责,但作为护理人员,我们确实需要分担责任。如果我们真的打算明智地使用多种数据来源,以提高个人或群体的全球健康状况,我们就需要清楚地了解数据的多个层面,从而获得真正的数据文化。长期以来,病历一直是令人失望和倦怠的根源,而现在病历的复兴指日可待,特别是随着技术解决方案的出现,我们在现场记录数据的工作将更加自动化和便利化。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
[The computerized medical record. From lost illusions to the hope of renewal].

Although the principle of recording and transmitting patient data is not new, the computerized medical record used in today's practice of care still does not meet the needs. We can easily - and often rightly - cast shame on the designers of those medical records and on administrators of our care institutions, but we as caregivers do need to share responsibility. If we really intend to use multiple sources of data wisely, in order to increase global health status at the individual level or for a population, we need to understand clearly the multiple dimensions of data and therefore acquire a real data culture. The revival of the medical record, for too long a source of disillusionment and burnout, is within reach especially as technical solutions appear to automate and facilitate our work of recording data in the field.

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