摘要
目的探讨利用医院信息标准化,指导电子病案标准化。方法文献查阅法结合个人总结。结果归纳出与电子病案发展相关的标准如HL7医院电子信息交换标准、医学数字化影像通信标准DICOM、SNOMED编码、国际疾病分类、ASTM制定的有关医疗标准、NDC国家药品编码、统一的医学语言系统等,对电子病案发展提供了规范化和标准化依据。结论我国医院信息标准化可借鉴发达国家医院信息标准化,在相对成熟的医院信息标准的基础上结合本国医院信息的现状制定出适合我国医院信息标准,加快电子病案的发展,解决电子病案在标准化方面的瓶颈问题,更有效地为临床、教学、研究、管理服务。
Objectvie To study the influence of standardization of hospital information to development of electronic medical records. Methods Literature consulting combined with personal summary. Results We summarized standard relevant to development of electronic medical records, such as HL7 hospital electronic information exchange standard, Digital Image Communication Standard of Medical （DICOM）, SNOMED codes, International Classification of Diseases, relevant medical standard formulated by AS T M, National Drug Codes（NDC）, unified medical language system, etc, to provide normalization andstandardization basis for development of electronic medical records. Conclusions Hospital information standardization of our country could learn from developed countries. Based on relative mature hospital information standard, combined with current status of hospital information of our own country, information standard suitable for hospital of our country should be formulated to accelerate development of electronic medical records, solve bottleneck problems of standardization of electronic medical records, and serve clinical, teaching, research and management more effectively.
出处
《中国病案》
2009年第10期33-34,共2页
Chinese Medical Record
关键词
医院信息
标准
电子病案
hospital information
standard
electronic medical records
