上海市某大型三甲综合性医院临床科研信息系统建设路径分析  

Analysis of the clinical research information system construction of a tertiary grade A comprehensive hospital in Shanghai

作　　者：张嵬[1] 朱鹏熹 陈剑伟[1] 魏民[1] 孙平波[1] 孙心岩[1] 张从昕[1] Zhang Wei;Zhu Pengaci;Chen Jianwei;Wei Min;Sun Pingbo;Sun Xinyan;Zhang Congacin(Changhai Hospital, Second Military Medical Universi ty , Shanghai 200433, P. R. China)

机构地区：[1]上海长海医院,200433

出　　处：《中华医学科研管理杂志》2018年第4期297-299,共3页Chinese Journal of Medical Science Research Management

摘　　要：目的介绍上海市某大型三甲综合性医院建设临床科研信息系统的具体做法。方法在数据库建设的基础上，进行了住院与手术记录病历、门诊病历以及辅诊报告的结构化设计，并开发了应用终端。结果开发了一套针对研究型病例、涵盖临床研究各环节的全链路规范化的临床科研信息系统，可以提供个性化定制的结构化数据。结论该临床科研信息系统为临床医学研究提供了便利，其做法具有一定的借鉴意义。Objective To introduce the construction of clinical research information system of a tertiary grade A comprehensive hospital in Shanghai. Methods Based on the database construction, the structured inpatient medical records, surgical records and ancillary diagnostic report are designed and the application terminal is developed. Results A full-link normalized clinical research information system for research-based eases covering all aspects of clinical research is developed, which can provide customized and structured data. Conclusions The clinical research information system provides con venience for clinical medical research, and its practice has certain reference significance.

关 键 词：临床医学研究 临床科研信息系统 结构化数据采集 

分 类 号：R197.323[医药卫生—卫生事业管理]