健康档案中的患者识别  

Person Identification and Quality of Health Care

作　　者：刘丹红[1] 李红蕾[1] 徐勇勇[1] 

机构地区：[1]第四军医大学卫生信息研究所,陕西西安710032

出　　处：《中国卫生质量管理》2010年第3期66-68,共3页Chinese Health Quality Management

基　　金：国家自然科学基金资助项目(90612012)

摘　　要：目的正确识别健康档案中卫生服务对象的信息及其标准化表达,为防止医疗事故和差错、提高医疗服务质量提供条件。方法参照国外研究结果和常规做法,遵照国际电子健康报文交换标准HL7患者标识(PID)数据段的内容,结合我国实际,综合分析。结果对相关数据项采用HL7的XPN、XAD和XTN复合数据类型进行结构化表达,并制定必须的分类编码标准,实现个体标识信息的标准化描述。结论制定了规范、统一的个体标识信息标准,并应用于各类健康记录。Objective To identify and determine the data items and their standard representations that should be used in identification of subjects of health care. Method Referring to international researches and practices, according to patient identification segment （ PID ） in HL7 messages, and making use of person＇s identifiers currently available in China. Result Some of the 30 data items in HL7 PID segment were constrained by using of certifications being applied in China, such as legal resident identity card, number of medical document, number of health card, and number of medical insurance card. For some data elements, the HL7 compound data types XPN, XAD and XTN were adopted for their structural descriptions, and coding systems needed were provided. Finally, a standardized person identification data set was developed. Conclusion Identifying a person accurately is of great importance in quality improvement of health care. Developing consistent standard for person identifying information based on international and domestic experiences is essential and viable.

关 键 词：个体标识 健康记录 卫生服务 质量标准化 

分 类 号：R197.1[医药卫生—卫生事业管理]