CAJ | 학술논문

本文简介我院以电子病历（EMR）为核心，自主研发的结构化门诊EMR系统。在使用过程中，提取医院信息系统（hIS）中病人基本信息，辅以相关专科疾病模板，规范了门诊病历的书写格式，实现了门诊病历的电子结构化。
본문간개아원이전자병력（EMR）위핵심，자주연발적결구화문진EMR계통。재사용과정중，제취의원신식계통（hIS）중병인기본신식，보이상관전과질병모판，규범료문진병력적서사격식，실현료문진병력적전자결구화。
This paper takes the 180th Hospital of pLA as an example to demonstrate that the hospital independently develops a structurized outpatient EMR (Electronic Medical Records) system on the basis of EMR. Through extraction of patients' basic information from HIS ( Hospital Information System) and adoption of relevant formats from clinical departments, the system standardizes format of medical records and realizes the structurization of EMR.