医学英语口语:以病人为中心的医疗保健

医学英语口语：以病人为中心的医疗保健

if patient-centered medicine is to become a widespread

reality in academic medical centers, educational initiatives

must include reform of the medical record. the medical record

is part of the hidden, or informal, curriculum of medical

school and residency that defines for students and residents

the essential ingredients of competent medical care. whatever

its merits, the conventional, problem-oriented medical record

(pomr) is a pathology-oriented record that helps perpetuate a

disease-focused, biomedical model of practice

如果以病人为中心的医学成为现实，在所以的教学计划中也就应该包含医疗记录的改革。常规的、以疾病为中心的医疗记录（pomr）也就是病理记录，它有助于维护以疾病为中心的生物医学模式。

patient-centered medicine requires a patient-centered

medical record (pcmr), one that addresses the person and

perspective of the patient as competently as it addresses the

patient's disease. the author proposes a pcmr that includes a

concise, upfront patient profile; speaks of "chief concerns,"

not "chief complaints"; makes patient perspective a captioned

component of the history of present illness; replaces the

pomr's formula soap (subjective, objective, assessment, plan)

with hoap (history, observations, assessment, plan); includes

important patient perspectives on the problem list; and calls

for additional, written attention to the person and

perspective of the patient throughout the course of medical

care

以病人为中心的医学就要有一份以病人为中心的医疗记录（pcmr），它的对象是人。它要用主要问题来取代主诉；hoap

（history, observations, assessment, plan）来取代soap(subjective, objective, assessment, plan)…。

patient-centered records can guide and teach clinicians

at every level of training and experience to practice

patient-centered medicine. moreover, such records can also

provide measurable evidence that this teaching has been

successful.

以病人为中心的病历记录能够指导并教育各级临床医务人员实践以病人为中心的医学，而且这些记录也为评价教育情况提供了量化证据。