基于XML的半结构化电子病历录入方法研究

Research on the Input Method of Semi-structured Electronic Medical Records Based on XML

目的:探索电子病历文档录入的新方法。方法:研发基于HL7标准的XML编辑器,通过基于XML的存贮,利用元素实现结构化录入,控制准确录入功能等方法来实现电子病历半结构化录入。结果:已在全国上百家医院应用,具有易操作性、书写高效的特点。结论:开发编辑器是基础,半结构化录入是应用的前提,XML是存储结构的关键,元素是决定录入效率的主要因素,易维护的模板是推广的有力保证。

Objective To explore a new method of electronic medical records document entry. Methods： The research anddevelopment of XML editor based on HL7 standard, through the XML based on the realization of the use of structured storage, inputelements, accurate control input function and other methods to achieve semi-structured data entry for electronic medical records.Results： In the 100 national hospital application, easy operation, high efficiency characteristic of writing. Conclusion： The developmentof the editor is the foundation, semi-structured data entry is the application premise, XML is the key element of the storage structure,element is the main factor to decide the input efficiency, easy maintenance of the template is a powerful guarantee for promotion.