摘要
本文简介我院以电子病历(EMR)为核心,自主研发的结构化门诊EMR系统。在使用过程中,提取医院信息系统(HIS)中病人基本信息,辅以相关专科疾病模板,规范了门诊病历的书写格式,实现了门诊病历的电子结构化。
This paper takes the 180th Hospital of PLA as an example to demonstrate that the hospital independently develops a structurized outpatient EMR （Electronic Medical Records） system on the basis of EMR. Through extraction of patients＇ basic information from HIS （ Hospital Information System） and adoption of relevant formats from clinical departments, the system standardizes format of medical records and realizes the structurization of EMR.
出处
《中国医疗设备》
2013年第9期92-93,共2页
China Medical Devices
关键词
门诊电子病历
医院信息系统
HL7
结构化电子病历
outpatient electronic medical records
hospital information system
HL7
structurizedelectronic medical records
