摘要
为满足结构化病案检索、临床路径、DGRs等不同层面对医疗信息标准化的需求,以新版电子病历结构化诊断功能为契机,通过对临床诊断与手术操作名称标准库的构架设计,构建内容、构建方法、录入系统的开发等方面研究,构建全新的标准的临床诊断字典库(方位库、诊断库、病理库、分期分型库、补充库)、手术操作名称字典库(方位库、手术操名称库)。实现临床疾病诊断与手术操作名称的统一命名,规范临床医师对疾病诊断与手术操作的命名,提高疾病诊断与手术操作名称标准化水平,为医疗信息标准化的实现奠定了重要的数据基础。
To meet the variable requirements of structured medical record retrieval, clinical pathwayand DGRs for the standardized medical information. By taking the opportunity to use the structured diagnosticmodule of the new version of electronic medical record, the framework, contents, methods and input system ofthe standard dictionary for clinical diagnosis and operations and procedures were designed and developed. A newstandard clinical diagnosis dictionary database （ orientation dictionary, diagnosis dictionary, pathologydictionary, stage classification dictionary, supplementary dictionary） and a new operations and proceduresdictionary （orientation dictionary, operations and procedures dictionary） were constructed. The uniform namingof clinical diagnosis and operations and procedures wererealized, which could standardize the clinicians′namingof disease diagnosis and operations and procedures, improve the standardization level of disease diagnosis andoperations and procedures, and lay an important data foundation for the standardized medical information.
作者
张萍
陈学涛
唐自云
周来新
Zhang Ping;Chen Xuetao;Tang Ziyun;Zhou Laixin(Medical Record Statistics Room,Xinqiao Hospital ofArmy Medical University（Third Military Medical University）Chongqing 400037,China;Department ofInformation,Xinqiao Hospital of Army Medical University（Third Military Medical University）Chongqing400037,China;Southwest Hospital of Army Medical University（Third Military Medical University）Chongqing400038,China)
出处
《中华肺部疾病杂志（电子版）》
CAS
2018年第5期644-646,共3页
Chinese Journal of Lung Diseases(Electronic Edition)
基金
重庆市社会事业与民生保障科技创新专项(cstc2017shmsA0886)
关键词
操作分类
疾病与手术
临床诊断
手术操作名称
临床字典库
Classification
Disease and operation
Clinical diagnosis
Operations andProcedures
Clinical dictionary database
