Integrated care and the working record
Integrated care and the working record
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综合护理和工作记录
DOI：
--
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发表时间：
2004
影响因子：
3
通讯作者：
Geraldine Fitzpatrick
中科院分区：
文献类型：
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作者：
Geraldine Fitzpatrick
默认情况下，电子健康记录或综合护理记录的许多讨论和规范通常将记录概念化为被动信息存储库。本文介绍的数据从一个案例研究的工作在一个大都市医院的医疗单位。它展示了临床医生如何定制，重新呈现和增强临床信息，以支持他们自己在为个体患者提供护理方面的作用。这被称为工作记录：一套复杂的相互关联的以临床医生为中心的文件，这些文件在当地形成、维护和使用，以支持提供护理，并与病人出院时存储在病历部门的以病人为中心的图表相结合。综合护理记录如何支持本地的可定制性和灵活性，支持这一工作记录，从而支持实践的影响。
By default, many discussions and specifications of electronic health records or integrated care records often conceptualize the record as a passive information repository. This article presents data from a case study of work in a medical unit in a major metropolitan hospital. It shows how the clinicians tailored, re-presented and augmented clinical information to support their own roles in the delivery of care for individual patients. This is referred to as the working record: a set of complexly interrelated clinician-centred documents that are locally evolved, maintained and used to support delivery of care in conjunction with the more patient-centred chart that will be stored in the medical records department on the patient’s discharge. Implications are drawn for how an integrated care record could support the local tailorability and flexibility that underpin this working record and hence underpin practice.