住院病案首页信息的共享与标准化

目的探讨病案首页的信息共享与标准化方法。方法根据《国家卫生信息标准基础框架》与《国家卫生数据字典》,通过扩展标记语言(XML)Schema对病案首页的文档结构与具体元素分别进行定义。结果定义了病案首页信息的Schema文档,将首页信息划分为患者的基本信息、临床信息和费用信息3部分,定义文档结构;首页中每一个数据项映射到《国家卫生数据字典》中对应的数据元,定义元素的属性;根据确定的XML Schema文档形成了XML Schema图。结论XML技术与数据元知识相结合,为病案首页信息在不同信息系统间的共享提供了一个可行的标准化方法。

Information Sharing and Standardization of the Abstract of Inpatient Records

Objective To explore a method of information sharing and standardization by an example of the abstract of inpatient records.Methods According to the Chinese National Health Information Framework and Health Data Dictionary,the general structure and entries of the abstract of inpatient records were defined by XML Schema.Results The XML Schema of the abstract of inpatient records were defined by dividing the information of the abstract of inpatient records into three parts and mapping every entry to the corresponding data element of Health Data Dictionary.According to the Schema,the Schema figures and the exchange format of XML file were created.Conclusion The paper proposed a feasible standard-driven solution to exchange patient encounter information among different parties and information systems.