中西医临床疾病诊断知识库的构建与应用

Construction and Application of Clinical Disease Diagnosis Knowledge Base in Traditional Chinese and Western Medicine

目的建设临床疾病诊断知识库,以此为基础,使用多疾病要素结构化录入方式,实现中西医临床诊断规范化,满足临床诊断、病案编目的规范化需求。方法在疾病诊断基础库的基础上,梳理疾病要素,建立疾病-要素关联关系、中西医病名对照关系、中医病证关联关系,以结构化选择的方式辅助临床医生诊断疾病,输出信息完备的规范化诊断结果。结果中西医临床疾病诊断知识库能辅助医生准确、迅速地完成主要诊断、中医主病、中医主证等的规范化录入。结论应用临床疾病诊断知识库能够增强临床疾病诊断录入的规范性,提高临床诊断的合理性、全面性、便捷性,同时为病案编目工作打下坚实基础,提高编目效率。

Objective To build a knowledge base for clinical disease diagnosis,realize the standardization of clinical diagnosis in traditional Chinese and Western medicine by structured input of multiple disease elements basing on the knowledge base,and to meet the standardization needs of clinical diagnosis and medical record cataloguing.Methods Based on the basic database of disease diagnosis,sort out the disease elements,establish the disease element correlation relationship,the disease name comparison relationship between traditional Chinese and Western medicine and the disease syndrome correlation relationship of traditional Chinese medicine,assist clinicians in diagnosing diseases in a structured way,and output standardized diagnosis with complete information.Results The clinical disease diagnosis knowledge base of traditional Chinese and Western medicine can assist doctors to accurately and quickly complete the standardized input of main diagnosis,main diseases of traditional Chinese medicine and main syndromes of traditional Chinese medicine.Conclusion The application of clinical disease diagnosis knowledge base can enhance the standardization of clinical disease diagnosis input and improves the rationality,comprehensiveness and convenience of clinical diagnosis.At the same time,it lays a solid foundation for medical record cataloging and improves the cataloging efficiency.