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目的探讨利用医院信息标准化,指导电子病案标准化。方法文献查阅法结合个人总结。结果归纳出与电子病案发展相关的标准如HL7医院电子信息交换标准、医学数字化影像通信标准DICOM、SNOMED编码、国际疾病分类、ASTM制定的有关医疗标准、NDC国家药品编码、统一的医学语言系统等,对电子病案发展提供了规范化和标准化依据。结论我国医院信息标准化可借鉴发达国家医院信息标准化,在相对成熟的医院信息标准的基础上结合本国医院信息的现状制定出适合我国医院信息标准,加快电子病案的发展,解决电子病案在标准化方面的瓶颈问题,更有效地为临床、教学、研究、管理服务。
Objective To explore the standardization of hospital information and guide the standardization of electronic medical records. Method literature review combined with personal summary. Results The criteria related to the development of electronic medical records such as HL7 hospital electronic information exchange standard, DICOM, SNOMED code, international classification of diseases, relevant medical standards developed by ASTM, NDC national drug code, unified medical language system and so on , Provided the standardization and standardization basis for the development of electronic medical records. Conclusion Standardization of hospital information in our country can learn from the standardization of hospital information in developed countries. Based on the relatively mature information standard of hospital, the information standard of hospital in our country is formulated in line with the current situation of hospital information in our country to speed up the development of electronic medical record and solve the standardization of electronic medical record Bottlenecks, more effective for clinical, teaching, research, management services.