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双轨病历构建
引用本文:何小菁, 季国忠. 双轨病历构建[J]. 医学与哲学, 2022, 43(6): 40-45. doi: 10.12014/j.issn.1002-0772.2022.06.08
作者姓名:何小菁  季国忠
作者单位:①. 南京医科大学医政学院 江苏南京 211166; ②. 南京医科大学第二附属医院党委办公室 江苏南京 210003
摘    要:

医学实践内容不断扩展,以身体哲学为基础的人文医学进路逐渐清晰,现有标准化病历却没有人文医学空间,需要重新构建双轨病历。双轨病历包含人文医学实践与生物医学实践,是病历管理模式的必然方向。双轨病历的记录内容、记录方式,将成为医学现阶段的一个重要研究课题。在分析生物医学病历书写与叙事医学病历书写之后,全面设计双轨病历,目的是使人文医学与生物医学的实践有机相融,完整、全方位记录全人医学实践。实现双轨病历的关键基础是借助信息技术,利用人文医学本体,智能化记录医学实践是未来的发展方向。



关 键 词:双轨病历   人文医学   生物医学
收稿时间:2022-02-17
修稿时间:2022-02-27

Construction of Dual Track Medical Record
HE Xiao-jing, JI Guo-zhong. Construction of Dual Track Medical Record[J]. Medicine & Philosophy, 2022, 43(6): 40-45. doi: 10.12014/j.issn.1002-0772.2022.06.08
Authors:HE Xiao-jing  JI Guo-zhong
Affiliation:①. School of Health Policy & Management, Nanjing Medical University, Nanjing 211166, China
Abstract:Along with continuous exploration in medical practice contents, the approach of humanistic medicine based on body philosophy becomes distinct. Present standard medical record leaves no space for humanistic medicine, so it is necessary to reconstruct the dual track medical record. Dual track medical record includes humanistic medicine practice and biomedical practice, which is an inevitable direction for medical record management mode. The recording content and recording mode are important research topics at present. After analyzing the writing of biomedical medical record and narrative medical record, the writer comprehensively designs the dual track medical record in order to fully blend the practice of humanistic medicine and biomedicine, and to record the whole person's medical practice in a complete and all-round way. The key basis of dual track medical record is information technology. Its future development lies in smart medical recording mode based on humanistic medicine.
Keywords:dual track medical record  humanistic medicine  biomedicine
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