目的分析美军在延续现场救护(prolonged field care,PFC)中医疗文书记录的经验做法,为促进我军战伤救治理论体系发展提供借鉴。方法通过查阅文献资料,梳理美军在PFC中常用的医疗文书记录类型、内容及作用。结果美军PFC医疗文书记录主要...目的分析美军在延续现场救护(prolonged field care,PFC)中医疗文书记录的经验做法,为促进我军战伤救治理论体系发展提供借鉴。方法通过查阅文献资料,梳理美军在PFC中常用的医疗文书记录类型、内容及作用。结果美军PFC医疗文书记录主要包括:DD1380 TCCC卡、PFC流程图、交接报告、行动报告和远程医疗服务指南等,且美军在PFC临床实践指南中,给出了PFC救护的基本策略(即应遵循“最低”“更高”“最佳”的原则),并提供了相应的PFC记录文书建议。结论我军可参考美军医疗文书记录的内容,优化设计伤票和野战病历,提高战伤救治能力。展开更多
Information technology have changed information media by networking and internet using technology in health as same as another part improve efficiency and effectiveness. Currently, the medical document is reality-base...Information technology have changed information media by networking and internet using technology in health as same as another part improve efficiency and effectiveness. Currently, the medical document is reality-based medicine, so that is the most important, richest and the most realistic source of medical and health information. Health information management systems that require systems to the storage, retrieval, storage and elimination of health records (by law), and adjust to the rules of professional. These processes are difficult and time consuming for human. In the meantime semantic HIM seem best solution.展开更多
文摘目的分析美军在延续现场救护(prolonged field care,PFC)中医疗文书记录的经验做法,为促进我军战伤救治理论体系发展提供借鉴。方法通过查阅文献资料,梳理美军在PFC中常用的医疗文书记录类型、内容及作用。结果美军PFC医疗文书记录主要包括:DD1380 TCCC卡、PFC流程图、交接报告、行动报告和远程医疗服务指南等,且美军在PFC临床实践指南中,给出了PFC救护的基本策略(即应遵循“最低”“更高”“最佳”的原则),并提供了相应的PFC记录文书建议。结论我军可参考美军医疗文书记录的内容,优化设计伤票和野战病历,提高战伤救治能力。
文摘Information technology have changed information media by networking and internet using technology in health as same as another part improve efficiency and effectiveness. Currently, the medical document is reality-based medicine, so that is the most important, richest and the most realistic source of medical and health information. Health information management systems that require systems to the storage, retrieval, storage and elimination of health records (by law), and adjust to the rules of professional. These processes are difficult and time consuming for human. In the meantime semantic HIM seem best solution.
