取与存:浅谈医院病案的产生与功能

V. Hess, Sophie Ledebur
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引用次数: 13

摘要

本文试图以柏林慈善医院的病历为基础,重构精神病学病历的产生及其变迁功能。病人文件的发展受到三个方面的影响:首先,最早的文件,从18世纪初开始,随着不同的办公技术进入医院病房,变得越来越结构化。其次,在狭义的医疗记录仍然是私密性的情况下,慈善医院病房的正规报告制度成为临床教育的重要组成部分。最后,随着19世纪70年代末医院记录重组为双重档案系统,记录的科学作用日益明显,从而允许临床医生系统地使用和选择患者档案用于研究目的。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Taking and Keeping: A Note on the Emergence and Function of Hospital Patient Records
The paper attempts to reconstruct the emergence and the changing function of medical recording in psychiatry based on the records of the Charité Hospital in Berlin. The development of patient documentation was influenced by three aspects: firstly the earliest documents, from the early 18th century, became increasingly structured as diverse office technologies entered the hospital's ward at this time. Secondly while medical recording in the narrow sense remained private, the regular and formalized reporting system in the hospital wards of the Charité became an important part of clinical education. Finally the growing scientific role of the records became evident with the reorganisation of the hospital record into a double filing system in the late 1870s, thus allowing the clinicians to use and select patient files systematically for research purposes.
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