今天看了一篇国外文献，关于病历的书写格式探讨，感觉很新鲜。特转发。
Leveraging（杠杆作用） systems thinking to design
patient-centered clinical documentation systems
Adam S. Rothschilda, Linda Dietrichb, Marion J. Ball b,c,∗,
Heidi Wurtzb, Holly Farish-Huntb, Nhora Cortes-Comererb
a Department of Biomedical Informatics, Columbia University, New York, NY, USA
b Healthlink Incorporated, Houston, TX, USA
c Johns Hopkins School of Nursing, 5706 Coley Court, Baltimore, MD 21210, USA
Received 29 June 2004;received in revised form 23 March 2005;accepted 23 March 2005
本文是美国哥伦比亚大学的生物信息研究所教授所写。文章阐述了以病人为中心的临床文档系统的设计思路，初看此文好像是一位护理人员所写，通过进一步研究，发现论述的不是一种病历的书写过程，而是哪一种病历的书写更适合于电子病历的研发。以下是文章的摘要及部分相关内容：
Summary A hospital is a type of system, yet healthcare information technology
(IT) has largely failed to view it as such. The failure to view the hospital as a system
has contributed to the practice of inefficient and ineffective clinical documentation.
This paper seeks to address how current clinical documentation practices reflect and
reinforce inefficiency and poor patient care. It also addresses how rethinking clinical
documentation and IT together may improve the entire healthcare process by promoting a more integrated and patient-centered healthcare information paradigm.
Rethinking IT in support of clinical documentation from a system-oriented perspective
may help improve patient care and provider communication.
我认为的论文精华内容：
Our approach, called the problem-driven health record (PDHR), is similar to the POMR （problem-oriented medical record) in that the problem list also plays a central role. It is different, however, in three major ways. First, the PDHR paradigm is not nearly as strict as the POMR paradigm. In the strict POMR, a separate progress note in the ubjective—objective-assessment-plan (SOAP) format is written for each problem, and information that is relevant to more than one problem is recorded redundantly. The PDHR does not require this redundant recording of information. Second, the PDHR is designed to be implemented in an EHR rather than on paper. It is designed to integrate other traditionally distinct) EHR activities, such as order entry and results review, into the documentation process. Third, it utilizes a controlled medical terminology (CMT) with which to record problems. Using a CMT enables easy downstream reuse of problem data for many purposes such as triggering problem-speci.c decision support rules and aiding in reimbursement, research, operations management, and public health reporting.
