子宫内膜异位症中医结构化门诊病历模板的构建

Creation of Structurized Out-patient Record Template of Endometriosis in Chinese Medicine

本文叙述了子宫内膜异位症中医结构化门诊病历模板的设计思路。病历模板分为初诊记录和复诊记录两种类型。其中的各个模块根据中医妇科的临床与科研要求以及子宫内膜异位症的疾病特性进行结构化处理设计。本研究构建的子宫内膜异位症中医结构化门诊病历模板,不但能满足临床记录和处理病历的要求,而且由于其结构化特性和较为广泛的覆盖面,为积累科研用原始数据打下了坚实的基础,为促进中医药对重大疾病的防治提供客观依据。

This article introduces the design of structurized out- patient record template of endometriosis treatment in Chinese Medicine. The record template included first visit record and return visit record,and each module was structurized due to the need of clinic and scientific research in Chinese Medicine gynecology,and also the disease characteristics of endometriosis. The structurized endometriosis clinical record template created in this study will not only meet the needs of clinical history recording,but due to its structurized characteristic and wide coverage,it also will lie a solid foundation for accumulating the original data in research. And even more,it will provide the objective evidence for the development of Chinese Medicine in disease prevention and treatment.