摘要
目的 开发新一代电子病历系统,实现临床医生结构化描述语言信息快速采集,方便临床信息集成与数据复用。方法 建立电子病历结构化描述语言模型,将临床规范化数据与描述性文本信息融为一体,实现重要医疗事件的表达和标识,达到临床信息的有效利用和医生快速数据录入。讨论 该模型实现了电子病历的模板表达和医生自由文本数据录入,通过自然语言实时处理技术,保障了电子病历的质量控制。结论 结构化描述语言电子病历模型允许医生自由文本数据录入,支持临床信息复用以及结构化数据处理,能实现临床数据快速采集,具有临床文档质量控制功能,是新一代电子病历发展的重要方向。
Objective To develop new electronic health records that facilitates rapid capture of narrative observations from clinicians, with clinical information integration and reuse. Methods We propose a design in which unstructured text and coded data fused to a single model called structured narrative, which can speed up data entry by clinicians. Natural language processing is used to quality assurance of clinical documents. Conclusion Structured narrative has potential to facilitate capture of data directly from clinicians by allowing freedom of expression, giving immediate feedback, which is the important direction of new electronic health records application.
出处
《中国卫生信息管理杂志》
2011年第1期59-63,共5页
Chinese Journal of Health Informatics and Management
关键词
电子病历
结构化描述语言
临床文档架构
自然语言处理
Electronic Health Records, Structured Narrative Model, Clinical Document Architecture, Natural Language Processing
