本文選題：醫(yī)學(xué)編輯器　切入點(diǎn)：電子病歷　出處：《中南民族大學(xué)》2012年碩士論文

【摘要】：隨著醫(yī)療信息學(xué)在理論研究和工程實(shí)踐上的發(fā)展，醫(yī)療信息化技術(shù)已經(jīng)得到越來越廣泛的應(yīng)用，醫(yī)療衛(wèi)生服務(wù)逐步進(jìn)入數(shù)字化、信息化的時代，，并取得了許多成果。然而在推行的醫(yī)療信息化建設(shè)進(jìn)程中也遇到了一些問題，其中醫(yī)療信息共享技術(shù)是需要解決的問題之一。 要解決醫(yī)療信息共享問題，需要從醫(yī)學(xué)信息標(biāo)準(zhǔn)化和不同信息系統(tǒng)之間互操作性兩個方面入手。醫(yī)學(xué)報(bào)告作為記錄病患的醫(yī)學(xué)信息（如生命體征、病史、過敏史、病歷、檢查影像等等）的主要載體，其對于醫(yī)療信息共享的作用是基礎(chǔ)性的。針對這一問題，本論文設(shè)計(jì)開發(fā)了一個專用醫(yī)學(xué)編輯器系統(tǒng)。 該系統(tǒng)在處理醫(yī)學(xué)報(bào)告文檔的導(dǎo)入、導(dǎo)出、編輯操作過程中，采用支持HL7交互的XML格式，即可以很好地滿足醫(yī)療信息標(biāo)準(zhǔn)化問題，又可以滿足醫(yī)生在編輯醫(yī)學(xué)報(bào)告方面的基本功能需求。 在系統(tǒng)中設(shè)計(jì)了醫(yī)用編輯修改痕跡保留功能，主要用于將醫(yī)療過程中產(chǎn)生的報(bào)告內(nèi)容和所有修改痕跡保留起來作為醫(yī)療行為證據(jù)供日后調(diào)閱審查。 針對醫(yī)學(xué)報(bào)告中的文本和檢查影像部分融合問題，在編輯器中實(shí)現(xiàn)了嵌入標(biāo)準(zhǔn)DICOM格式影像的閱片功能，有效地將醫(yī)學(xué)影像和報(bào)告整合在一起。經(jīng)過試驗(yàn)測試，本文所設(shè)計(jì)開發(fā)的醫(yī)學(xué)編輯器完成了與現(xiàn)有的PACS和EMRs的系統(tǒng)集成，具備良好的實(shí)用性。
[Abstract]:With the development of medical informatics in theory research and engineering practice, medical information technology has been more and more widely used. Medical and health services have gradually entered the era of digitization and informatization, and many achievements have been made.However, some problems have been encountered in the process of medical information construction, among which medical information sharing technology is one of the problems to be solved.In order to solve the problem of medical information sharing, the standardization of medical information and the interoperability of different information systems should be started.As the main carrier of medical information (such as vital signs, medical history, allergies, medical records, examination images, etc.), medical reports are fundamental to the sharing of medical information.In order to solve this problem, a special medical editor system is designed and developed in this paper.In the process of processing the import, export and edit of medical report documents, the system adopts XML format which supports HL7 interaction, that is, it can well meet the problem of medical information standardization.It can also meet the basic functional needs of doctors in editing medical reports.In the system, the function of medical editing modification trace retention is designed, which is mainly used to keep the report content and all the modified traces produced in the medical process as evidence of medical behavior for later review.Aiming at the fusion of text and inspection image in medical report, the function of embedding standard DICOM format image into the editor is realized, which can effectively integrate medical image and report together.The medical editor designed and developed in this paper has been integrated with the existing PACS and EMRs system, and has good practicability.
【學(xué)位授予單位】：中南民族大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2012
【分類號】：R318.0

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