【摘要】：研究背景及目的：顱腦創(chuàng)傷因高傷殘率和高死亡率已成為基礎(chǔ)研究和臨床研究的熱點(diǎn)和重點(diǎn)，但目前臨床研究大都缺乏大樣本、標(biāo)準(zhǔn)化的數(shù)據(jù)支撐，導(dǎo)致了研究結(jié)果的針對(duì)性、適用性與臨床需求存在一定的偏差。同時(shí)目前顱腦創(chuàng)傷病歷大都為非結(jié)構(gòu)化病歷系統(tǒng)，信息填寫為文本格式，記錄描述的隨意性大、不規(guī)范、缺項(xiàng)多，使相關(guān)創(chuàng)傷和其救治信息難以歸納、統(tǒng)計(jì)、比較和分析，存在有病例、無數(shù)據(jù)的現(xiàn)狀。本研究依托顱腦創(chuàng)傷病歷，病歷進(jìn)行結(jié)構(gòu)化研究，結(jié)合顱腦創(chuàng)傷救治路徑、救治規(guī)范與計(jì)算機(jī)結(jié)構(gòu)化數(shù)據(jù)庫理論，對(duì)顱腦創(chuàng)傷病歷信息按照顱腦創(chuàng)傷發(fā)生、急救、入院治療、出院、救治過程等記錄信息進(jìn)行結(jié)構(gòu)化分拆，并與顱腦創(chuàng)傷數(shù)據(jù)庫相適應(yīng)，初步形成顱腦創(chuàng)傷結(jié)構(gòu)化電子病歷－數(shù)據(jù)庫結(jié)構(gòu)，為建立標(biāo)準(zhǔn)、規(guī)范顱腦創(chuàng)傷結(jié)構(gòu)化電子病歷－數(shù)據(jù)庫系統(tǒng)奠定基礎(chǔ)，為開展顱腦創(chuàng)傷臨床研究提供數(shù)據(jù)平臺(tái)。方法：1、探討制定科學(xué)、合理的顱腦創(chuàng)傷病歷內(nèi)容結(jié)構(gòu)化模塊與標(biāo)準(zhǔn)化的表達(dá)方式；2、探討建立顱腦創(chuàng)傷結(jié)構(gòu)化病歷和顱腦創(chuàng)傷�？茢�(shù)據(jù)庫結(jié)構(gòu)的目標(biāo)，并完成需求分析；3、基于后臺(tái)數(shù)據(jù)庫平臺(tái)（SQL Sever）以及.net3.5框架，以C#語言進(jìn)行軟件編寫，研發(fā)顱腦創(chuàng)傷結(jié)構(gòu)化病歷-數(shù)據(jù)庫錄入系統(tǒng)軟件；4、通過測試錄入顱腦損傷住院病歷，分析數(shù)據(jù)庫的性能，并初步分析兒童和青少年顱腦創(chuàng)傷救治情況。結(jié)果：1、確定了顱腦創(chuàng)傷結(jié)構(gòu)化病歷的具體內(nèi)容、表達(dá)方式與說明，實(shí)現(xiàn)顱腦創(chuàng)傷病歷數(shù)據(jù)結(jié)構(gòu)模塊化，建立結(jié)構(gòu)化病歷的內(nèi)容形式及其表達(dá)方式；2、初步形成顱腦創(chuàng)傷結(jié)構(gòu)化電子病歷－數(shù)據(jù)庫錄入系統(tǒng)結(jié)構(gòu)，編寫了顱腦創(chuàng)傷結(jié)構(gòu)化電子病歷－數(shù)據(jù)庫錄入系統(tǒng)軟件；3、通過顱腦創(chuàng)傷救治信息的錄入與統(tǒng)計(jì)分析,證明了本顱腦創(chuàng)傷結(jié)構(gòu)化病歷數(shù)據(jù)庫能較科學(xué)、全面地收集顱腦創(chuàng)傷病歷資料,具有對(duì)顱腦創(chuàng)傷數(shù)據(jù)進(jìn)行分析和后期管理的性能,但也存在與實(shí)際臨床工作對(duì)接和收集顱腦創(chuàng)傷資料完整性等方面的困難；4、通過兒童和青少年顱腦創(chuàng)傷資料分析,初步顯示兒童顱腦創(chuàng)傷救治的流行病學(xué)特點(diǎn),可以為該年齡段顱腦顱腦創(chuàng)傷預(yù)防提供依據(jù)。結(jié)論：通過對(duì)顱腦創(chuàng)傷病歷結(jié)構(gòu)化的研究，，證明建立適合顱腦損傷病歷結(jié)構(gòu)化電子病歷-數(shù)據(jù)庫是可行的；該軟件結(jié)構(gòu)合理，內(nèi)容科學(xué)，功能實(shí)用，表與表間關(guān)系清楚。其操作界面簡單方便，能夠較好的滿足臨床顱腦創(chuàng)傷病歷資料統(tǒng)計(jì)分析，有助于我們掌握顱腦創(chuàng)傷的流行學(xué)特征，研究分析影響顱腦創(chuàng)傷發(fā)生、急救、轉(zhuǎn)運(yùn)、院內(nèi)救治等各個(gè)環(huán)節(jié)的相關(guān)因素，為深入研究顱腦創(chuàng)傷的預(yù)防與救治提供數(shù)據(jù)支撐，為顱腦創(chuàng)傷防治決策者提供參考依據(jù)，進(jìn)而提高我國顱腦創(chuàng)傷防、診、治水平和質(zhì)量，也為顱腦創(chuàng)傷病歷進(jìn)一步電子化研究打下基礎(chǔ)。
[Abstract]:Background and objective: traumatic brain injury has become the focus of basic and clinical research because of its high disability rate and high mortality. However, at present, most of the clinical studies lack of large sample and standardized data support, which leads to the pertinence of the research results. There is a certain deviation between applicability and clinical requirements. At the same time, at present, the medical records of craniocerebral trauma are mostly unstructured medical records, the information is written in the form of text, and the description of the records is arbitrary, irregular and lacking, which makes it difficult to sum up, statistics, compare and analyze the relevant trauma and its cure information. There are cases and no data. This research relies on the craniocerebral trauma medical record, carries on the structural research of the medical record, unifies the craniocerebral trauma rescue path, the treatment standard and the computer structured database theory, according to the craniocerebral trauma medical record information, first aid, admission treatment, In order to establish the standard for establishing the standard, the structured electronic medical record database structure of craniocerebral trauma was initially formed according to the structured separation of the information recorded in the discharge and treatment process and the adaptation of the database to the brain trauma database. To standardize the structured electronic medical record-database system for craniocerebral trauma and provide a data platform for clinical research on traumatic brain injury. Methods: 1) to explore the establishment of scientific and reasonable structural modules and standardized expression methods of the contents of the medical records of craniocerebral trauma, 2) to explore the goal of establishing the structure of structured medical records and specialized databases of craniocerebral trauma, and to complete the requirement analysis; 3. Based on the background database platform (SQL Sever) and .net3.5 framework, the software is written in C # language to develop the software of structured medical record of TBI-database input system. 4. The performance of the database was analyzed by inpatients with craniocerebral injury, and the treatment of traumatic brain injury in children and adolescents was preliminarily analyzed. Results: 1. The concrete content, expression and explanation of the structured medical records of traumatic brain injury were determined, the data structure of the patients with craniocerebral trauma was modularized, and the content form and expression mode of the structured medical records were established. (2) the structure of structured electronic medical record (EMR) -database input system was formed, and the software of structured EMR database input system was compiled. 3. Through the input and statistical analysis of the information about the treatment of craniocerebral trauma, it is proved that the structured medical record database of craniocerebral trauma can collect the data of the medical records of the patients with craniocerebral trauma in a more scientific and comprehensive way. It has the capability of analyzing and managing the data of traumatic brain injury, but it also has difficulties in docking with the actual clinical work and collecting the integrity of the data of traumatic brain injury. 4. By analyzing the data of traumatic brain injury in children and adolescents, the epidemiological characteristics of the treatment of children with traumatic brain injury were preliminarily revealed, which could provide evidence for the prevention of traumatic brain injury in this age group. Conclusion: it is proved that it is feasible to set up a structured electronic medical record database for craniocerebral injury cases by studying the structure of the case history of craniocerebral trauma, the software is reasonable in structure, scientific in content, practical in function, and clear in relation between tables and tables. The operation interface is simple and convenient, which can satisfy the statistical analysis of the clinical traumatic brain injury medical records. It is helpful for us to grasp the epidemiological characteristics of the traumatic brain injury, and to study and analyze the influence on the occurrence, first aid and transportation of the traumatic brain injury. The related factors in hospital treatment and other links provide data support for further study on the prevention and treatment of traumatic brain injury, provide reference basis for decision makers of prevention and treatment of traumatic brain injury, and then improve the level and quality of prevention, diagnosis and treatment of craniocerebral trauma in China. It also lays a foundation for further electronic research on the case history of craniocerebral trauma.
【學(xué)位授予單位】：瀘州醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2013
【分類號(hào)】：R651.15;TP311.13

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