血管外科结构化电子病历设计及应用前景研讨

Design and discussion on application prospects of structured electronic medical records in vascular surgery

基于国内外文献检索及既往病历书写、临床科研经验确定数据结构化节点,通过设计病历书写选择框、逻辑引用、信息系统互联影像、检验系统等方法建立结构化病历模板并在实际临床工作中应用评估,以此设计涵盖多种血管外科疾病的智能化、结构化病历系统,规范临床医师病历书写,提升病历质量,为后期临床科研提供结构化数据支持,并为血管外科专病数据库建设提供了工作基础。

Based on worldwide literature retrieval,past medical record writing experiences,and clinical research experience,data structured nodes are determined. Structured electronic medical record templates are established by multimethods including design medical record writing selection boxes,logical citations,and interconnect hospital information system with radiology system and medical laboratory systems,etc. Application and estimation were performed in clinical experiences to design an intelligent and structured electronic medical record system covering various of vascular diseases,standardizing the writing of medical records of clinicians,improving the quality of medical records and providing structured data support for later clinical research,and providing a working foundation for the construction of a database for vascular surgery.