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由于日益增多且复杂的医学信息,加之人工书写病历的不完善、有效时间分配间的不协调等都需要病历采集的计算机化。在推广前,医生们应了解这一系统的指征、效果和可能出现的问题。部分或全部病历的计算机化指征需要医生事先提出,如对生活方式的建议,按系统约定改进,提供诊断的方法,协助非医务人员也能做出诊断等。病史可由病人自己、中间协助人员、公卫专业人员或医生进行输
Due to the increasing number and complexity of medical information, in addition to the imperfections of the manual writing medical records and the inconsistency of effective time allocation, computerization of medical record collection is required. Before the promotion, doctors should understand the system’s indications, effects, and possible problems. The computerized indications of some or all of the medical records need doctors to propose in advance, such as suggestions for lifestyle, improve according to system conventions, provide methods for diagnosis, and assist non-medical personnel to make diagnosis. The medical history can be lost by the patient himself, assistants in the middle, public health professionals or doctors.