健康体检报告首页信息的概念框架与参考样式单研究

目的构建健康体检报告首页信息的概念框架和参考样式单，为健康体检机构数据收集与整理、受检者健康信息监测与管理提供参考。方法遵循国家卫生部健康体检相关规范，以11家国内健康体检机构体检报告的数据项为基础，制定健康体检报告首页信息概念框架与核心数据元，基于概念框架设计健康体检报告首页参考样式单。结果建立的体检报告首页概念框架包括4个维度（标识信息、健康相关信息、体检结果摘要、健康评估与健康指导）、16个子维度、52个核心数据元和25个数据元值域代码表，设计的体检报告首页参考样式单的结构、内容与概念框架的维度、子维度、核心数据元相一致。结论健康体检报告首页可为受检者健康摘要信息的结构化与规范化表达，摘要数据的计算机化获取提供一条可行的方法。首页中部分数据项的选取和填写格式设置还需在实际使用中进一步进行检验与完善。

A conceptual framework for synopsis of information of health examination reports and its style sheet

Objective To develop a conceptual framework for the synopsis of information of health examination reports （HERs） and its style sheet so as to provide a reference for information collection and management in health examination institutions. Methods A conceptual framework for the synopsis of information of HERs and its core data elements were developed based on HERs items from 11 health examination institutions, and a style sheet for the synopsis of information of HERs was then designed. Results The conceptual framework included 4 dimensions （e. g. identification information, health-related information, health exam summary, health evaluation and guidance ）, 16 sub-dimensions, 52 core data elements and 25 value domains. The structure and content of the designed sheet were consistent with the dimensions, sub- dimensions and core data elements of the conceptual framework. Conclusions The developed synopsis of information of HERs could be a feasible solution for structured and standardized representation of clients＇ health examination information. The selection and filling of some items should be validated and refined in the future.