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目前,医院信息系统已由管理信息为主向以病人信息为中心的方向发展,计算机更多地参与临床医疗工作,如辅助医生的病历书写、病案管理的病案电子化存储、各种检查申请与结果的传递、病案信息的检索与提取、远程医疗和远程教学等,以上直接对病历电子化提出了要求,电子病历是医院信息管理的发展趋势,而病历的结构化是电子病历信息后续处理的基本要求。
At present, the hospital information system has evolved from management information to patient information as the center. Computers are more involved in clinical medical work, such as assisting doctors in the writing of medical records, electronically storing medical records in case management, and various inspection applications. The transfer of results, the retrieval and retrieval of medical record information, telemedicine, and distance learning, etc., directly impose requirements on the electronic medical records. Electronic medical records are the development trend of hospital information management, and the structure of medical records is the follow-up treatment of electronic medical record information. basic requirements.