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目前医疗资源信息化已成为发展趋势,中医电子病历对于中医学的发展及中医信息化建设非常重要。本文从中医电子病历的研究现状着手,提出了我院肝病结构化中医电子病历系统的设计思路,即中医电子病历要体现中医的特点,以整体观和辨证论治的思想为指导;要实现结构化、标准化和规范化,这是对病案信息进行挖掘和利用的前提和基础;能够实现数据挖掘的功能,分析总结疾病的发生发展规律以及疾病之间的各种关系,使之成为科研工作的有力工具。文章对该系统实现过程中的难点及对策进行了分析,解决了术语不规范、诊断不统一等问题,实现了一个比较完善的肝病结构化中医电子病历系统。
At present, the informationization of medical resources has become a trend of development. The electronic medical records of Chinese medicine are very important for the development of Chinese medicine and the construction of Chinese medicine informatization. This paper starts from the current research status of TCM EHR and puts forward the design idea of TCM structured EHR system in our hospital. That is to say, EHR should embody the characteristics of TCM and take the holistic view and syndrome differentiation as guidance. Standardization and standardization, which is the prerequisite and basis for the mining and utilization of medical record information. It can realize the function of data mining, and analyze and summarize the occurrence and development of diseases as well as the various relationships between diseases, making it a powerful tool for scientific research. The article analyzes the difficulties and countermeasures in the realization process of the system, solves the problems of non-standard terms and inaccurate diagnosis, and realizes a comparatively perfect structured electronic medical record system of liver disease.