电子病历与标准化和结构化

Standardization and Structure of Electronic Medical Record

电子病历被认为是医疗信息化最为重要的一个环节,但是长久以来电子病历的概念在医学信息学研究、医疗信息产业、医院信息主管和临床人员中始终存在理解上的差异,试图从病历的历史使命来探究电子病历的内涵,并从标准化和结构化出发分析建设电子病历需要关注的核心问题,为研究和建设电子病历系统提供一种新的思路。

The electronic medical record is considered as the most important link in medical information, however, the concept of it bears different understandings in medical informatics research, medical information industry, hospital information director and clinical personnel for a long time. This paper tries to explore the connotation of electronic medical record from the history task of record, and analyze the core problem of constructing electronic medical record from standard- ization and structure, which provides a new thought for researching and constructing electronic medical record system.