武威新型电子健康档案系统的文档架构  

作　　者：梁英[1] 杨鹏[1] 杨喆[1] 潘峰[1] 谭志军[1] 刘丹红[1] 徐勇勇[1] 

机构地区：[1]第四军医大学卫生信息研究所,西安市710032

出　　处：《中国卫生信息管理杂志》2012年第2期65-71,共7页Chinese Journal of Health Informatics and Management

基　　金：国家科技重大专项:武威市乙肝防治示范区建设与现场流行病学研究(2009ZX10002-027)

摘　　要：目的建立居民电子健康档案的文档架构,用于整合武威全市现有和将要记录的城乡居民健康文档,并指导武威新型电子健康档案系统开发。方法遵循业务规范和国内外信息标准,以武威市纸质健康档案表单为基础,根据表单的业务内容将文档体分解为内容模块,每个内容模块进一步拆分为可以结构化表达的数据元组。结果提取出的一级内容模块共32个,其中文档头包含12个内容模块,文档体包含20个内容模块。复杂的一级内容模块可以多层嵌套。通过2个实例,说明这些内容模块可以组建家庭建档、个人建档、健康体检、乙肝流调等13类事件19个文档。结论通过少数通用的封闭的内容模块和数据元组,表达业务内容与时俱进的个性化健康档案电子文档,是卫生信息标准化的重要内容之一。武威新型电子健康档案系统的实践说明,用内容模块和数据元组构建电子健康档案系统的文档架构是可行的。Objective The research objective was to build an electronic health record document structure, which was used for integrating the existing health documents as well as those would be recorded in the future and providing guidance on establishing the new electronic health records system at Wuwei. Methods Following the business standards as well as international and domestic health information standards, and taking paper-based health records at Wuwei as the bases, we divided the body of the document into content modules according to the business table sheets. In turn,we divided the content modules into organizationally expressed data element groups. Results We extracted 32 primary level content modules, which included 12 content modules in the header and 20 in the body.In addition, some complex primary level content modules were multilevel-nested with sub-level content modules. The feasibility of building 13 acts and 19 documents, which applied in family, personal health, health examination, HBV epidemiology investigation and so on,was explicated through two instances. Conclusion It is one of the main contents of health information standardization to express individualized advancing electronic health record documents via few universal and close content modules as well as data elements groups.The Wuwei experience proves that it is feasible to develop document structure for the electronic health records system with content modules and data element groups.

关 键 词：电子健康档案 电子健康档案系统 内容模块 数据元组 

分 类 号：R-058[医药卫生] R197.324