电子病历临床决策系统的建立与应用  

Establishment and Application of Clinical Decision System of Electronic Medical Record

作　　者：郑金龙 穆大力 解芳 史亚坤 宫辉 李昊 连九峥 王越 朱萧 党军红 

机构地区：[1]中国医学科学院整形外科医院,北京市100144

出　　处：《中国病案》2017年第10期45-47,共3页Chinese Medical Record

基　　金：北京协和医学院协和青年基金(3332016039)

摘　　要：随着电子病历的深入实践,单纯的电子病历编辑功能已无法满足当前临床工作需要。为向临床医师提供科学准确的诊疗信息支持,提高医师工作质量、减少医疗差错,本文对电子病历临床决策智能化推理进行研究,通过建立某医院临床知识库,利用信息处理语义转换技术,建立整形外科电子病历临床决策系统。该系统通过对患者主诉、现病史、专科情况等进行信息分析,自动推理出诊断方案,通过对手术适应证、术前辅助检查结果、诊断对应手术等进行信息分析,自动推理出手术方案,通过对手术过程描述进行信息分析,自动推断出术后诊断,并提供智能推理建议。基于语义技术的电子病历临床决策系统是解决电子病历智能化推理的可行方式。With the deep practice of electronic medical records, a simple electronic medical record editing function has been unable to meet the current clinical work needs. To provide clinicians with scientific and accurate diagnosis and treatment information to support, improve the quality of doctors work to reduce medical errors. In this paper, the clinical decision-making of clinical diagnosis and treatment of electronic medical records, through the establishment of a hospital clinical knowledge base, the use of information processing semantic conversion technology, the establishment of plastic surgery clinical data processing system, the system through the patient complaints, history, specialist situation and other information Analysis, automatic reasoning out of the diagnostic program, through the surgical indications, preoperative diagnosis results, diagnosis of the corresponding operation and other information analysis, automatic reasoning out of the surgical program, through the description of the surgical process of information analysis, automatically infer the postoperative diagnosis, and Provide intelligent reasoning recommendations. The clinical decision system of electronic medical records based on semantic technology is a feasible way to solve the intelligent reasoning of electronic medical records.

关 键 词：电子病历 临床决策 语义技术 智能推理 

分 类 号：R197.323[医药卫生—卫生事业管理]