基于AbiWord的结构化电子病历系统研究  

Research on the Structured Electronic Medical Record System Based on AbiWord

作　　者：熊志刚[1] 尚浩[1] 

机构地区：[1]华中科技大学同济医学院附属同济医院计算机中心

出　　处：《中国数字医学》2017年第2期45-47,共3页China Digital Medicine

基　　金：国家高技术研究发展计划(863计划)-医疗信息化体系与信息标准研究(编号:2012AA02A617)~~

摘　　要：当前电子病历多由医生手工录入完成,是件复杂而细致的工作,并且自然语言记录的医疗数据也无法直接应用于数据挖掘处理。基于半结构化处理思想,结合Abi Word自身处理优势,提出了一种电子病历结构化编辑系统。利用XML结构化描述特性,组建XML知识库,再按照不同病历文档类型需求,从XML知识库中选取所需元素组装成病历模板,医生只需在模板上进行选择及适当的自由文本输入即可完成病历书写工作。本系统不仅能减轻医生手工书写电子病历的负担,而且能从XML格式的病历文档中,直接定位搜索所需数据,方便生成病案首页,利于医疗数据挖掘和进一步处理利用。Completing the current electronic medical records by a doctor＇s manual entry, is a complex and meticulous work, moreover the natural language record of medical data cannot be directly applied to data mining processing. So in this paper, based on semi-structured processing ideas, combined with the processing advantages of AbiWord, we propose a structured electronic medical records editing system. We utilize XML structural description feature to construct XML knowledge base, then we can select the required elements from knowledge base to assemble into medical record templates. The doctor can complete medical records written work by choosing and writing proper free text input in the template. This system not only can reduce the burden of doctor＇s hand writing electronic medical records, but also can directly find the required data from the records of XML format document. So we can easily generate medical record, which will help data mining and further processing.

关 键 词：结构化 可扩展标记语言 病历模板 

分 类 号：R319[医药卫生—基础医学]