基于CDA L1/L2标准实现扫描病历与电子病历文档的融合  

The Fusion of Standard Implementation of Scanning Medical Records and Electronic Medical Records Document Based on CDA L1/L2

作　　者：吴金波[1] 杨勇[1] 苏韶生[1] 何远源[1] 

机构地区：[1]中山大学附属中山医院信息科

出　　处：《中国数字医学》2015年第2期105-106,112,共3页China Digital Medicine

摘　　要：基于医疗机构内部大量的手写病历与电子病历割裂,难以实现一致化管理利用的问题所在,结合HL7 CDA标准和软件技术,提出将手写病历扫描后以HL7 CDA L1为依据实现标准化,来实现与电子病历文档格式的兼容,解决一致化的利用及管理的目的。将HL7 CDA L1标准作为历史和现有的手写病历的转换标准,可达到与电子病历的CDA文档无缝融合,实现基于内容结构的一致化的存储、呈现、利用和管理要求,实现了历史病历资源的再生利用,并且为历史病历资源的跨区域的共享提供了有利基础保障。Within the medical institutions large handwritten medical records and electronic medical records were separated,it is difficult to achieve the consistent management and utilization.combined with the software technology of HL7 and CDA standard,put forward by HL7 CDA handwritten medical record scanning L1 as the basis to realize the standardization,to achieve compatibility with document format of electronic medical records,to solve the utilization and management agreement the purpose.Conclusion：the HL7 CDA L1 standard as the conversion of history and the existing handwritten medical record standards,can achieve seamless integration with the CDA document of electronic medical records,realize the request of content and structure of the uniform storage,presentation,use and management based on historical records,realize regenerative resource use,and the sharing of cross regional historical records resources,provide favorable foundation guarantee.

关 键 词：CDA标准化 扫描病历 电子病历 融合管理 

分 类 号：R319[医药卫生—基础医学] TP319[自动化与计算机技术—计算机软件与理论]