颈椎病专病电子病历数据集团体标准研究  

A Group Standard Study on Specialized Electronic Medical Record Dataset of Cervical Spondylosis

作　　者：戎天华 林琳[2] 杨昕 张俊丽 吴炳轩[1] 桑大成 刘宝戈[1] Rong Tianhua;Lin Lin;Yang Xin;Zhang Junli;Wu Bingxuan;Sang Dacheng;Liu Baoge(Department of Orthopedics,Beijing Tiantan Hospital Affiliated to Capital Medical University,Beijing 100070,China;不详)

机构地区：[1]首都医科大学附属北京天坛医院骨科,北京市100070 [2]首都医科大学附属北京天坛医院信息中心,北京市100070 [3]首都医科大学附属北京天坛医院国家神经系统疾病临床医学研究中心,国家神经系统疾病医疗质量控制中心,北京市100070 [4]北京嘉和美康信息技术有限公司,北京市100085

出　　处：《中国病案》2023年第8期9-12,40,共5页Chinese Medical Record

基　　金：国家自然科学基金(81972084,82272524);北京市自然科学基金(7222051);北京市卫生健康科技成果和适宜技术推广项目(BHTPP202033)。

摘　　要：随着电子病案系统的广泛应用,颈椎病专病医疗数据呈指数级增长,但现有数据尚存在形式混乱、维度不足、互通性差等问题。某院骨科牵头,参考卫生信息国家标准与行业标准,结合颈椎病领域数据规范与专家共识,研究制订《颈椎病专病电子病历数据集团体标准》。课题组通过文献检索、查阅电子病历系统、回顾现有科研用病例报告表及专家函询等方式对专病数据集中各个数据元进行定义、编码与溯源求证,最终形成团体标准文件。本团体标准中的专病数据集共包括332个数据元,由入院记录、治疗记录与评估量表三部分组成,可进一步细分为12个模块,适用于颈椎病诊断、治疗与评估三个维度中关键特征的标准化录入。本研究将有助于加强临床医师、信息工程师与管理人员对颈椎病医疗数据结构的理解,并发挥团体标准在颈椎病专病临床诊疗与科学研究中的指导、规范与质控作用。In recent years,with the wide application of electronic medical record system,the medical data of cervical spondylosis has increased exponentially,but the existing data still have some problems,such as chaotic form,insufficient dimension and poor interoperability.Therefore,the department of Orthopedics surgery of our hospital took the lead in formulating the"Group Standard for Specialized Electronic Medical Record Dataset of Cervical Spondylosis"by referring to the national and professional standards of health information,combining with the data standard and expert consensus in the field of cervical spondylosis.By means of literature review,electronic medical record system,review of existing scientific case report forms and expert letter consultation,we defined,coded and traced the source of each data element in this disease-specific data set,and wrote the Group Standard documents.The specialized dataset in this Group Standard included a total of 332 data elements,which were summarized into three parts,admission records,treatment records and assessment scales,and could be further subdivided into 12 modules,which were suitable for the standardized entry of key features in the three dimensions of cervical spondylosis,namely diagnosis,treatment and assessment.The present study will help to strengthen the understanding of the medical data structure of cervical spondylosis in clinicians,information engineers and medical administrators,and empowered this group standards in the guidance,standardization and quality control of clinical diagnosis,treatment and scientific research of cervical spondylosis.

关 键 词：颈椎病 电子病历 数据集 团体标准 

分 类 号：R681.55[医药卫生—骨科学] R197.323[医药卫生—外科学]