基于标准化术语的胸外科结构化电子病历实践

摘要

As an important carrier in the information construction of modern hospitals, electronic medical record is becoming more and more refined and intelligent. This paper introduces the standardized and structured electronic medical record system of thoracic surgecal department and puts forward the effect evaluation and prospect.%电子病历作为现代化医院信息化建设中的重要载体,越来越往精细化、智能化方向发展.本文就胸外科标准化、结构化电子病历系统进行介绍,并提出效果评价和展望.