医院病历信息数据化的路径与方法研究

Research on Digitalization Path and Method of Hospital Medical Records Information

目的:基于回顾性研究设计,探讨将医院病历信息转化为可分析数据的路径和方法,解决文本信息数据化的问题,以提高统计结果的可信度。方法:以中医药治疗小儿脑瘫的医院病历信息为例,经过研究目的确定、指标确定、指标定义与术语标准化、编码与赋值、数据库设计、数据录入、质量控制、数据库锁定8个步骤,得到了包含研究相关指标的数据库。结果:建立了一套基于医院病历信息的指标提取与转化为数据的路径和方法。结论:在回顾性研究中,将文本信息转化为可统计数据是关键环节,指标的提取与数据化应该遵循研究方案,注意对人群、治疗方案、评价指标等关键要素进行系统分析,以确保研究指标的系统完整性。

Based on a retrospective study design, this article was aimed to discuss the transformation path and method of hospital medical records information into analyzable data, in order to solve the problem of text-based information digitalization, and improve the credibility of statistical results. The hospital medical records information of traditional Chinese medicine （TCM） treatment for infantile cerebral palsy was taken as example. After the identification of research purpose, the study contained 8 steps, which were index identification, index definition, coding and assignment, database design, data entry, quality control, and database locking. The database contained research-related indicators was received. The results showed that a set of path and method based on indicator extraction and conversion of hospital medical records information into data. It was concluded that in the retrospective study design, the conversion of text information into analyzable data was the key step. Extraction and digitalization of indicators should be based on the research plan. Key elements such as the crowd, treatment plan, evaluation indicator, should be paid attention to for the systematic analysis, in order to ensure the system integrity of research indicators.