中医电子病历系统工作现状及展望  

Work Status and Prospects of TCM Electronic Medical Records System

作　　者：董兴鲁[1] 曹克刚[1] 薛丹[1] 房位昊[1] 高颖[1] 李艳丽[2] 王家艳[3] 

机构地区：[1]北京中医药大学东直门医院,北京市100070 [2]中国康复研究中心北京博爱医院中医康复科,北京市100068 [3]海南省中医院,海口市527603

出　　处：《中国病案》2014年第6期50-52,共3页Chinese Medical Record

基　　金：中医药行业科研专项(201207001);北京中医药大学创新团队项目(2011-CXTD-22)

摘　　要：对中医电子病历系统临床应用情况调研,发现存在数据录入不便、智能化不足、病种特点未凸显、质量控制力度尚有不足等缺陷,应从术语标准化、症状关联、单病种模板制作与完善、系统升级及技术更新等角度提供解决方案。未来中医电子病历系统的智能化、质量控制及移动医疗集成等重要环节需要进一步改进。Through the research of TCM clinical application of electronic medical record system, we found that there were some defects such as the data entry inconvenience, intelligentize deficiencies, disease characteristics did not highlight, lack of quality control. We should provide solutions from some aspects such as terminology standardization, associated symptoms, single disease template making and improvement, system upgrades and technical update. In the future, the important links of intelligentize and quality control of TCM electronic medical record system and mobile medical intezration needs further imorovement.

关 键 词：中风病 单病种 电子病历 病历模板 

分 类 号：R197.32[医药卫生—卫生事业管理]