摘要
本研究将电子病历中结构化输入模式与自由化输入模式结合,设计并实现了一种电子病历结构化引导式输入模式。该模式不仅能引导病历书写者完成书写过程,杜绝病历内容漏项和缺项,还能训练和强化严谨的临床思维模式,促进低年资医师的培养。
This study designed and developed a guided structured data entry for configurable electronic medical record based on structured data entry and medical language entry. This model could guide the imputer finish history records without absent item, furthermore, it can train and strengthen residents for their clinical thought.
出处
《中国医疗设备》
2010年第6期44-46,共3页
China Medical Devices
基金
四川省卫生厅项目(303005002053)资助
关键词
HIS
电子病历
结构化
引导式输入模式
HIS
electronic medical record （EMR）
structuring
guided input mode
