基于XML的结构化电子病历临床诊疗数据库构建

随着医疗信息化的迅速发展，医院信息系统已从传统的以财务管理为核心向以病人为中心的临床信息系统转变。电子病历作为患者临床医疗信息的载体，集中反映了患者临床诊疗全部过程，是医院数字化之本。目前全国大多数医院实施了电子病历，实现了以数据库形式存储的患者信息到病历结构的转换，从而实现由以支持日常业务管理为目的的数据库描述到以患者为中心的描述。唐都医院使用的电子病历系统是基于HL7CDA标准和XML技术建立的半结构化电子病历，为更好的服务于临床医生，建立一个基于电子病历的临床诊疗数据库，为临床提供知识平台，方便医生书写病历时随时调用，并通过学习帮助医生提高诊疗水平。

Construction of Clinical Diagnosis and Treatment Database for Structured Electronic Medical Records based-on XML

Along the rapid development of medical information, hospitals are turning from traditional financial management based information system to patient based clinical information system. As the carrier of clinical information for patients, electronic medical record comprehensively reflects the process of clinical practices of patients, and it is the base of digital hospital. So far, most hospitals in China have adopted electronic medical record, changing from storing patients＇ information in database to medical records, which fulfills the transition from database aimed at daily management to system centered on patients. Our hospital adopted semi-structured electronic medical record based on HL7 CDA standards and XML technology. To provide better services to chnical doctors, a clinical diagnosis and treatment database based on clinical medical record is constructed, which can provide a platform of clinical knowledge, is convenient for doctors to use at any time, and is able to improve the diagnosis and treatment by learning.