电子病案结构和临床辅助决策系统设计

The structure of electronic medical record and the design of clinical accessorial decision system of Cancer Hospital

目的建立肿瘤医院电子病案的临床辅助决策系统和其他业务分析工具。方法分析肿瘤疾病和治疗过程的特点,以及临床业务分析的需要,提出与"病人—住院次"平行的"病人—治疗次"电子病案结构,设计实现这种双重结构的病历书写模版。结果在此结构基础上利用数据仓库工具建立临床辅助决策演示系统,包括治疗路径决策和治疗方案决策。结论建立临床辅助决策系统的关键是电子病案提供符合临床逻辑的结构和数据。

According to the need of cancer disease＇ s operation analysis and clinical demand, the electro medical record should have the diplex structure of patients and the times of being in hospital and patients and the times of therapy. Based on the structure, it is possible to set up the clinical acces- sorial decision system tool, including therapy progress decision and therapy program method decision by using the data warehouse.