基于HL7 v3 CDA的可交换影像结果报告设计与实现  

Interoperable Radiology Examination Report Based on HL7 V3 CDA R2

作　　者：章笠中[1] 曹世华[1] 梁俊[2] 许美芳 金瓯 

机构地区：[1]杭州师范大学 [2]浙江大学医学院附属第二医院,浙江省杭州市解放路88号310009 [3]浙江数字医疗卫生技术研究院

出　　处：《中国数字医学》2011年第7期30-33,共4页China Digital Medicine

基　　金：国家科技支撑计划项目(编号:2008BAH27B01;2008BAH27B03)~~

摘　　要：探讨了基于HL7 v3 CDA R2标准的影像结果报告的设计与实现方法。根据卫生部颁布的电子病历基本数据元、数据集,提出一套基于HL7 v3 CDA R2,面向文档,针对数据的本地化临床影像结果报告CDA文档模板,包括对影像报告的结构和语义进行定义,影像结果临床描述内容的表达,关键术语与模板的绑定,针对该CDA模板的自定义样式表文件,为影像结果信息的互操作在语法和语义2个层次上提供了一个可行的方法。To explore the design and realization of radiology examination result reports based on HL7 v3 CDA R2 standard. Following the base data element and the data set of the electronic medical record published by Chinese Ministry of Health, we provide a CDA document formwork focus on the local clinical iconography report based on HL7 v3 CDA R2, including the definition of the iconography report structure and the semantics, the clinical presentation of radiology examination report, the binding of the pivotal terminology and the formwork, and the user-defined style list for CDA formwork. These would provide a feasible method in the syntax and the semantics to interoperate the radiology examination report.

关 键 词：影像结果报告 HL7 V3 CDA R2 术语绑定 互操作性 

分 类 号：R445[医药卫生—影像医学与核医学]