中医临床护理信息数据元体系标准构建研究  

Research of Building Standard System of TCM Clinical Care Information Data Element

作　　者：张小红[1] 万长秀[1] 林玲[2] 

机构地区：[1]湖北省中医院,湖北武汉430061 [2]湖北中医药大学,湖北武汉430061

出　　处：《湖北中医药大学学报》2014年第4期111-113,共3页Journal of Hubei University of Chinese Medicine

基　　金：国家中医药管理局信息化建设专项--中医临床护理信息数据元研究(zyxx-20130015)

摘　　要：目的收集医院护理信息系统与电子病历相关的护理表单,提取相关信息数据元,编制《中医临床护理信息数据元目录》以及《中医临床护理信息数据元值域代码》。方法本研究为质性研究设计,采用文献研究、借鉴法以及现场调研与专家访谈法收集护理表单,采用自上而下法对中医临床护理信息数据元进行提取。结果初步收集中医临床护理信息数据元共计703个,并按照卫生信息数据元目录的17个分类的编制,将703个数据元进行整理、分类,编制《中医临床护理信息数据元目录》以及《中医临床护理信息数据元值域代码》。结论基本上完成中医临床护理信息数据元体系框架的构建及中医临床护理信息数据元目录及其值域代码的编制,探讨了中医临床护理信息数据元体系构建研究的方法学问题,为今后完善中医临床护理信息数据元标准体系提供参考。Objective To collect hospital care information systems and electronic medical records of nursing forms , extract relevant information data elements , make＂ TCM clinical care information data element directory ＂ and ＂Chinese yuan range of clinical care information data code ＂ . Methods This study is a prime research design , research literature , drawing collection law and field research and expert interviews care form , using the top - down method of TCM clinical care information data element extraction. Results Preliminary clinical medicine care information was collected a total of 703 data elements and according to 17 categories of health information data element directory ,703 data elements were sorted, classified and made into according to ＂ TCM clinical care information data dement directory ＂ and ＂Chinese yuan range of clinical care information data code ＂. Conclusions It basically completed TCM clinical care information system framework of data elements and TCM clinical care and range of information and data element directory code , and discussed the methodological problems of data elements of traditional Chinese medicine clinical care information system construction research problems, provide reference for the future improvement of clinical medicine care information data element standard system.

关 键 词：数据元 中医护理 标准化 

分 类 号：R248[医药卫生—中医临床基础]