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电子病历的临床决策支持
引用本文:刘阳,曾凡,黄昊,王禾. 电子病历的临床决策支持[J]. 重庆医学, 2009, 38(21)
作者姓名:刘阳  曾凡  黄昊  王禾
作者单位:第三军医大学大坪医院野战外科研究所信息科,重庆,400042;第三军医大学大坪医院野战外科研究所信息科,重庆,400042;第三军医大学大坪医院野战外科研究所信息科,重庆,400042;第三军医大学大坪医院野战外科研究所信息科,重庆,400042
摘    要:
目前电子病历正向智能化和知识化发展,其核心价值是满足临床诊疗现场的信息需求及能够有效地改善医生的临床决策支持.电子病历的开放式结构化数据录入使临床描述信息结构化,并使临床医疗和科研活动充分利用这些数据成为可能.

关 键 词:电子病历  临床决策支持  临床信息系统  结构化数据录入

Clinical decision support of electronic medical record
LIU Yang,ZENG Fan,HUANG Hao,et al.. Clinical decision support of electronic medical record[J]. Chongqing Medical Journal, 2009, 38(21)
Authors:LIU Yang  ZENG Fan  HUANG Hao  et al.
Affiliation:LIU Yang,ZENG Fan,HUANG Hao,et al.(Department of Information,Research Institute of Field Surgery,Daping Hospital,Third Military Medical University,Chongqing 400042,China)
Abstract:
The development of electronic medical record(EMR) is currently developing towards intellectualization and kmowledgization.The most important core value of EMR is to satisfy information needs of clinicians at the point of medical care and thus improve the quality of medical care by assisting the decision making process of clinicians.Open SDE is intended for structuring narrative data to make these available for both medical care and research.
Keywords:electronic medical record(EMR)  clinical decision support  clinical information system  structured data entry(SDE)  
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