Towards a multi-professional patient record--a study of the headings used in clinical practice.

Autor: Ahlfeldt H; Linköping University, Sweden., Ehnfors M, Ridderstolpe L
Jazyk: angličtina
Zdroj: Proceedings. AMIA Symposium [Proc AMIA Symp] 1999, pp. 7-11.
Abstrakt: This paper reports on the differences and similarities of headings used in patient records by Swedish health care professionals; nurses, occupational therapists, physiotherapists, dietitians, speech therapists, medical social workers and general practitioners. The background to the study is a national project where representatives from the different health care professions have worked together for two years in an effort to develop a multi-professional database of terms for the health care sector. The study reports on an analysis of the existing multi-professional lists of headings with respect to structure, degree of specialization, synonyms and homonyms. The study is descriptive in nature, gives a status report on the variety of headings used in clinical practice, provides necessary material for a normative approach focusing on a truly multiprofessional patient record in the future.
Databáze: MEDLINE