Objective To discuss the necessity of outpatient structured electronic medical record and build outpatient structured electronic medical record based on outpatient record features. Methods Outpatient structured electronic medical record was introduced into traditional outpatient medical station, and system structured interface was created to realize data connection. Then the data caching was used to reduce the burden of the database server, and structural language was design to realize semantic layer data exchange and sharing. Results The burden of the server was greatly reduced, and the interface had good expansibility. Conclusion Promoting the structured outpatient electronic medical records was helpful to improve the working efficiency of the medical staff, further implement the standardization of medical records, organic integrate and share the patient data, and ensure the work quality.%目的 探讨门诊结构化电子病历的必要性,并基于门诊病历的功能特点构建结构化电子病历.方法 在传统门诊医生站中引入结构化门诊电子病历,建立系统结构化接口以实现数据对接,利用数据缓存技术以减轻数据库服务器的负担,设计结构化语言以实现语义层数据交换与共享.结果 系统结构化接口的建立大大减轻了系统服务器的负担,且具有良好的扩展性.结论 推进门诊结构化电子病历的应用有助于提高医护人员的工作效率,进一步落实病历规范化,使患者的诊疗数据有机整合共享,从而保证医疗工作质量.
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