【作者】 李广曦；

【导师】 陈蔚文；

【作者基本信息】 广州中医药大学 ， 中西医结合临床， 2005， 博士

【摘要】 本研究从知识模型角度,以电子病历形式构建脾虚证的数据采集系统。系统以VISUAL BASIC6.0、VBA、SQL SERVER2000为工具,参考《脾虚证消化吸收障碍亚型的功能基因谱与模式识别研究课题科研病历临床观察表》,以客户端/服务器架构实现。包含了职员角色管理、职员隶属关系管理、病人挂号、最小数据元素管理,病案与病案模板录入,病案量化评分,审核记录导出,病案查询等模块。 本研究以最小数据元素形式拆分整篇病案,以树状结构形式定义病案最小数据元素的关联关系。提供多种树结构形式以体现病案元素之间多层次的生物医学信息的物理结构与意识结构。对最小数据元素的定义通过“知识编辑器”实现。定义的内容包括元素的数据类型,取值范围,计量单位,概念术语,树状编码,分值,角色属性,以及树结构的子节点触发器。触发器从数据元素的取值区间中划分出一个较小的区间,落在此区间内的父节点录入数据将会触发子节点元素的自动呈现。知识编辑器定义了电子病案第一层“模板”。 通过对电子病历第一层“模板”进行加工,最小数据元素集组成了电子病案的第二层“模板”。对第一层“模板”的加工包括隐藏不常用的数据元素,为元素添加一些提示性的颜色,采用不同的树状编码,不同的概念术语等等,以令模板符合临床的快速录入的需要,并起到一定警示作用,实现跨语言的病案录入应用。医务人员通过调用电子病案的第二层模板实现病案的录入。 最小数据元素的集合在某一时点的横切面上实现电子病案的数据的结构化。系统同时通过“病情发生时间”顺序,以面向时间方式逐个组织医疗事件,实现电子病历客观数据录入的纵向结构化。 在界面表现上,系统利用WORD的文本域功能,以自然文本段落形式组织数据元素,同时为不同数据类型的元素提供界面容器。更多还原

【Abstract】 We have designed and build a data collective system for Spleen and Stomach syndromes from the point of knowledge model taking the form of Electronic Medical Record. The System is constructed with VISUAL BASIC6. 0, VBA, and SQL SERVER2000, under the Client/Server Architecture. The system is composed of the following functional modules: Staff role administration, System login in and login out, Attaching relation administration, Patient registration, Minimum data elements administration, PR and PR template entry and review; PR quantitative audit.We split a patient record with the minimal data elements, defining the relationship between the elements with dynamic arbor structure in order to embody multi-levels bio-medical informatics physics structure and conscious structure in different special area and the individual varieties. Minimal data element definition is implemented by "Knowledge Editor" (KE). The definition involves element data type, value confine, measurement unit, concept term, arbor code, score, role prosperity and trigger of child node in the arbor tree. The trigger mark off a lesser section within the value scope. The entry data locating in this section will trigger off the automatic presentation of the child-node elements. The KE define the EMR template of the first level.By processing the EMR template of the first level, a set of minimal data elements (MDE) constitutes the EMR template of the second level. The process includes keeping in some data element which is not in common use, adding suggestive color to the element, introducing different arbor code and introducing different concept terms, which is necessary for the requirement of speediness entry or which can make caution and complete PR entry crossing different language. Medical staffs must transfer the template of the second level to entry data in a PR.The set of MDE structured the PR data in the transverse section at a certain occasion. To implements data structure on the portrait section, our system organizes each individual clinical event taking the form of time-orient according to the order of "Event Occurring Time".On the systematic interface, our system use the text field in WORD 2000 application to organize data elements in form of natural text paragraphs, provides interface container for elements of different data type.Our System provides quantifiable collated evaluation function for the PR being entried base on SDE. Score (power) of each element is defined in KE. Score of PR is calculated via measuring deviation against the "golden standard" PR. To guarantee the safety of PR data, our system provides data accessing three-parts authorization among "medical clerk" and "clinical-staff" and "PR administrator" and two-class data accessing authorization between junior and senior.Creativity of this study lies in PR Para graphic splitting in time order, minimum granularity design of PR data elements; multi-arbor framework design; automatically triggered presenting of data elements; natural-language-style更多还原