基于数据提取的门诊电子病历设计

摘要

Objective Establish an electronic medical record system which has simple recording , easy op-eration and accords with outpatient service .Methods Analyze the particularity of outpatient service business and the demand of outpatient electronic medical record , compare outpatient medical records with inpatient electronic medical records, establish an outpatient electronic medical record based on data extraction .Results The electronic medical record system based on the data extraction meet the requirements of the outpatient service business , and was operable and feasible.Conclusion The inpatient electronic medical record is not suitable for transferring to outpatient service business.Our electronic medical records can complete outpatient records collection quickly , and has an important significance to patients , doctors and hospitals.%目的：建立记录简单、操作方便、符合门诊业务特点的电子病历。方法通过分析门诊业务的特殊性和门诊电子病历的需求程度，比较门诊病历与住院电子病历之间的差异，提出采用数据抽取的方法建立门诊电子病历。结果基于数据抽取的电子病历符合门诊的业务要求，医疗信息丰富，具有可操作性和可行性。结论住院电子病历以及其建设思路不适合完全移植到门诊业务中，采用数据抽取的方法，自动生成电子病历能够快速完成门诊病历的收集储存，对患者、医师、医院都具有重要意义。