病毒性肝炎等传染病临床信息采集系统的构建  

To Build the Electronic Medical Record System of Viral Hepatitis,AIDS and TB

作　　者：骆真[1] 张启明[2] 刘保延[2] 王义国[2] 张磊[3] 刘中华[1] 徐志锐[1] 

机构地区：[1]山东中医药大学,济南250355 [2]中国中医科学院中医临床基础医学研究所,北京100700 [3]北京交通大学,北京100044

出　　处：《中国中医基础医学杂志》2013年第2期206-208,共3页JOURNAL OF BASIC CHINESE MEDICINE

基　　金：国家科技重大专项资助项目(2009ZX10005-019)

摘　　要：目的:构建体现中医辨证特点的艾滋病、病毒性肝炎、肺结核结构化临床信息采集系统。方法:基于传统关系型数据库ORACLE,运用DELPHI语言并采用C/S构架,在课题组提出的症状单元假说基础上对3种传染病临床术语进行规范,设计了3种传染病临床信息采集系统。结果:本系统实现了对3种传染病中医诊疗数据的结构化采集。结论:本临床信息采集系统第一次融入了艾滋病、病毒性肝炎、肺结核的特有信息,以患者最痛苦的症状及其临床特征作为临床信息采集的重点,突出了中医辨证的特点;以症状的轻重变化作为疗效评价指标,符合中医疗效评价的临床实际。Objective： To Build the structured electronic medical record system of AIDS, viral hepatitis and TB. Method： Based on the theory of symptomatic unit and the structure of traditional relational database Oracle, a structured medical record system is designed of three infectious diseases, which uses DELPHI language and C/S architecture. Result： TCM clinical datas concerning diagnosis and treatment were collected in a structured way. Conclusion： Specific information of three infectious diseases, such as clinical features of a symptom, was inset into the structured electronic medical record system for the first time. The system focuses on collecting the most painful symptoms and their clinical features which reflect characteristics of TCM pattern differentiation. Furthermore, the curative effects were evaluated on the basis of the changes of symptoms, which correspond with the reality of traditional Chinese medicine.

关 键 词：结构化临床信息采集系统 模块 辨证 症状 

分 类 号：R512.6[医药卫生—内科学]