[1]刘 勇,陈文生.电子病历术语规范化流程及临床辅助诊断系统设计[J].医学信息,2020,33(14):7-9.[doi:10.3969/j.issn.1006-1959.2020.14.003]
　LIU Yong,CHEN Wen-sheng.Electronic Medical Record Terminology Standardization Process and Design of Clinical Assistant Diagnosis System[J].Medical Information,2020,33(14):7-9.[doi:10.3969/j.issn.1006-1959.2020.14.003]
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电子病历术语规范化流程及临床辅助诊断系统设计()
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医学信息[ISSN:1006-1959/CN:61-1278/R]

卷:
33卷
期数:
2020年14期
页码:
7-9
栏目:
出版日期:
2020-07-15

文章信息/Info

Title:
Electronic Medical Record Terminology Standardization Process and Design of Clinical Assistant Diagnosis System
文章编号:
1006-1959（2020）14-0007-03
作者:
刘 勇; 陈文生
（1.南京江北人民医院信息中心，江苏 南京 210048；2.南京科技职业学院图书馆，江苏 南京 210048）
Author(s):
LIU Yong; CHEN Wen-sheng
(1.Information Center,Nanjing Jiangbei People’s Hospital,Nanjing 210048,Jiangsu,China;2.Library of Nanjing Vocational College of Science and Technology,Nanjing 210048,Jiangsu,China)
关键词:
电子病历; 术语; 规范化; 辅助诊断
Keywords:
Electronic medical records; Terminology; Standardized; Auxiliary diagnosis
分类号:
R197.323
DOI:
10.3969/j.issn.1006-1959.2020.14.003
文献标志码:
B
摘要:
结构化电子病历具有数据标准化程度高、数据检索方便的优点，能够为循证医学、科研、教学提供有效的信息支撑，电子病历数据录入的质量会影响临床管理和决策水平。本文首先分析了影响电子病历录入质量的相关因素，在此基础上提出了电子病历术语规范化流程，总结了关键技术、系统实现及界面设计经验，旨在为临床提供客观、准确的数据以及实现辅助临床诊断提供参考。
Abstract:
The structured electronic medical record has the advantages of high data standardization and convenient data retrieval, and can provide effective information support for evidence-based medicine, scientific research, and teaching. The quality of electronic medical record data entry will affect clinical management and decision-making. This article first analyzes the relevant factors that affect the quality of electronic medical record entry, on this basis, it proposes a standardized process of electronic medical record terminology, summarizes key technologies, system implementation, and interface design experience, and aims to provide clinical and objective data and implementation assistance provide a reference for clinical diagnosis.

参考文献/References:

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更新日期/Last Update: 1900-01-01