患者转诊信息及其结构化与标准化

根据我国医疗文书管理相关规定，遵循有关国际组织的健康文档标准化技术和方法，探讨了患者转诊时需要携带的个人健康信息的内容、文档结构以及数据标准化问题。转诊信息包括基本信息、转诊事件信息和临床信息三个方面，按照文档段／子文档段、数据组／子数据组、数据元等三个层次划分，形成包括10个文档段（子文档段）、18个数据组（子数据组）、123个数据元的转诊文档基本框架结构。文档段限定了所包含数据产生的背景和语境，数据组由一系列数据元组成。通过数据元属性描述进行标准化。研究表明，结构化和标准化的转诊文档可促进医疗信息传递中数据的准确、一致性理解。但有赖于共享范围内标准制定和应用的协调一致，目前我国还有大量的临床概念、术语和数据元有待标准化。

Patient's Referral Information and Structuring and Standardization

Objective To discuss and identify the data items should be included in patient referral record, and the way these data items be structured and standardized. Methods According to national and local regulations for medical records administration, and following technique approaches provided by international standard development organizations such as ISO, CEN, HL7, ASTM, Australian Institute of Health and Welfare, NEHTA, etc. UML was used in data modeling. Results Information in a referral document can be classified as three types： patient identification, referral event and clinical information, which were organized hierarchically in section~sub-section, data group/sub-data group and data element. A section provides the context for data creation. A data group is a composite data structure for holding related items of information, and can only be assigned values through the data elements that are contained within it. Conclusions Structured and standardized referral document can facilitate the consistent and ambiguous understanding of patients＇ data in information exchange. Referral as a specific health event, its document standardization relies on the harmonization of standard developing and adopting within the information sharing scope. There are large amount of medical concepts, vocabularies and data elements remained to be standardized and specified nowadays in China.