电子健康档案中标准化护理术语的应用进展  

Standardize nursing terminology in electronic health records

作　　者：弓宸 史润泽 康晓凤[1] 许洁萍[2] 张燕舞 Gong Chen;Shi Runze;Kang Xiaofeng;Xu Jieping;Zhang Yanwu(School of Nursing, Peking Union Medical College, Beijing 100144 China;School of Information, Renmin University of China, Beijing 100872, China;Institute of Medical Information, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100020, China)

机构地区：[1]北京协和医学院护理学院,100144 [2]中国人民大学信息学院,北京100872 [3]中国医学科学院,北京协和医学院,医学信息研究所信息服务部,100020

出　　处：《中国实用护理杂志》2019年第22期1757-1760,F0003,共5页Chinese Journal of Practical Nursing

基　　金：2017年度北京协和医学院研究生教育教学改革项目(10023201702502).

摘　　要：随着医疗卫生领域电子信息化发展,建立电子健康档案成为现代医疗服务的必要措施。本文阐述了电子健康档案中应用标准化护理术语的意义,介绍了标准化护理术语在电子健康档案中应用现状,分析了标准化护理术语研究面临的挑战及应对策略。With the development of informatization in healthcare system, it is necessary to build the electronic healthcare records. This article reviews the development and meanings of using the standardize nursing terminology in electronic healthcare records, and discusses the challenges and methods of the development of standardized nursing terminology in electronic healthcare records.

关 键 词：电子健康档案 标准化护理术语 护理信息学 

分 类 号：R47[医药卫生—护理学]