| 摘要 |
A documentation system that allows adequate control of documentation in addition to an assessment of skills of the professionals involved includes plurality of software modules, each software module dedicated to a particular disease process or body system. Each software modules provides a checklist of assessment steps or an anatomical diagram of a particular body system or medical terminology. The medical data is accessed by inputting the abbreviations of a particular disease process or medical term displayed on an electronic device. It can then be downloaded to a PC and printed out in hard copy to be temporarily placed on the chart of the patient during an acute-episode, incident or accident or be permanently placed in the patient's chart to describe the patient's condition. In addition the pertinent medical data may be given to the patient to assist the patient in understanding his/her disease process, medical condition or medical terms.
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