结构化电子病历的应用

摘要

国内医院的医疗信息管理系统中，电子病历系统是医院信息化建设的核心，随着《电子病历基本架构与数据标准（试行）》和《电子病历基本规范（试行）》等文件相继出台，建立以个人信息为主线的电子病历系统及电子病历结构化已经是电子病历发展的必然方向。结合医院信息系统实际情况，就结构化电子病历在医院信息管理系统的实施和应用，为医院实施应用电子病历系统提供参考。%In the medical information management system of domestic hospital, the electronic medical record system is the core of the hospital information construction. With the introduction of Basic Architecture and Data Standards of Electronic Medical Records (Trial) and Basic Specification of Electronic Medical Records (Trial), the establishment of electronic medical record system with the main line of personal information and structuralization of electronic medical records is the inevitable direction of the development of electronic medical records. In combination with the practical situation of information system in our hospital, the implementation and application of the structured electronic medical records in the hospital information management system provides reference for the implementation and application of electronic medical record system in the hospital.