摘要
病历档案是医务人员诊治患者疾患的原始记录.现通行的病案只反映生物技术医学实践过程,缺少人文社会医学实践记录,客观上需要对现有病案进行重构.文章通过对我国传统医学病案和现代生物技术医学病案管理的溯源,证明构建人文社会医学病案的必要性,并指出人文社会医学病案应具有医乃仁术、以患者为先、为患者赋权、医患共济的特征,可通过补充人文病历、整合叙事病历、设计全新病案表单、采用智能病案等方式予以构建.
Abstract
The medical record archives is one of important specialized files.Currently,medical records only reflect the practical process of biotechnology medicine and lack records of humanistic and social medicine practice.Objectively,it is necessary to reconstruct existing medical records.The article traces the origins of traditional medicine and modern biotechnology medicine in China through medical record management,proving the necessity of developing medical records in humanistic medical records.The article analyzes the characteristics that should be possessed in the development of humanistic and social medical records,namely,these records shall be benevolent,patient-first,empowering patients,and showing doctor-patient cooperation.It proposes the feasibility of developing humanistic and social medical records,and constructs humanistic and social medical records by supplementing humanistic medical records,integrating narrative medical records,designing new medical record forms,and adopting intelligent medical records.
维普
万方数据