摘要
目前电子病历正向智能化和知识化发展,其核心价值是满足临床诊疗现场的信息需求及能够有效地改善医生的临床决策支持。电子病历的开放式结构化数据录入使临床描述信息结构化,并使临床医疗和科研活动充分利用这些数据成为可能。
The development of electronic medical record （EMR） is currently developing towards intellectualization and kmowledgization. The most important core value of EMR is to satisfy information needs of clinicians at the point of medical care and thus improve the quality of medical care by assisting the decision making process of clinicians. Open SDE is intended for structuring narrative data to make these available for both medical care and research.
出处
《重庆医学》
CAS
CSCD
北大核心
2009年第21期2662-2663,共2页
Chongqing medicine
关键词
电子病历
临床决策支持
临床信息系统
结构化数据录入
electronic medical record （EMR）
clinical decision support
clinical information system
structured data entry （SDE）
