摘要
目的/意义建设前结构化电子病历数据管理体系,并探讨其对智慧医院建设水平和医院医疗、教学、科研、管理效能提升的影响。方法/过程基于现行电子病历系统管理模式,设计多层次前结构化电子病历数据管理体系和“写-存-转-用”关键技术路径,通过统一专病模板、统一字典标准和统一建设路径,实现电子病历数据的高效管理和利用。结果/结论规范化病历模板和数据管理体系有效赋能医院医疗、教学、科研、管理,提升了病历书写标准化水平和数据利用效率,为智慧医院建设提供了高质量的病历数据基础。
Purpose/Significance To establish a pre-structured electronic medical record(EMR)data management system,and to discuss its impact on the construction level of smart hospitals and the improvement of the hospitals’medical,teaching,scientific research and management efficiency.Method/Process Based on the existing management model of EMR systems,a multi-level data management model for pre-structured EMR and the key technical path of“writing-storage-transfer-utilization”are designed.By unifying disease-specific templates,dictionary standards and construction paths,efficient management and utilization of EMR data can be achieved.Result/Conclusion The implementation of standardized medical record templates and data management systems effectively empower hospital medical care,teaching,research,and management,enhancing the standardization level of medical record writing and the utilization efficiency of data,and laying a high-quality medical record data foundation for the construction of smart hospitals.
作者
陈婕卿
周翔
CHEN Jieqing;ZHOU Xiang(Peking Union Medical College Hospital,Chinese Academy of Medical Sciences,Beijing 100730,China)
出处
《医学信息学杂志》
2025年第9期85-89,94,共6页
Journal of Medical Informatics
基金
北京协和医院协和人才培育支持计划D类项目(项目编号:UHB12072)。
关键词
前结构化电子病历
智慧医院
智慧管理
pre-structured electronic medical records(EMR)
smart hospital
smart management
