CAJ | 학술논문

电子病历是数字化医疗的基础。虽然我国关于电子病历文档类型和文档段标识已有相关标准和规范，但仍缺乏电子病历文档内容和术语的标准和规范，难以纠正不同级别的医疗机构同一文档段的记录内容在结构和术语使用上的巨大差异，也无法利用大数据信息挖掘、知识发现等IT新技术，对我国丰富的电子病历数据资源库进行有效的二次利用。本文介绍了电子病历中单词、术语与受控术语的相关概念、用途和重要性，列举了患者主诉与临床检查结果表达的术语结构的概念框架，通过受控医学词汇结构与质量评价的12条评价要点，强调了电子病历内容结构与受控术语结构的标准化，在我国电子病历标准化工作中的重要性和紧迫性。
전자병력시수자화의료적기출。수연아국관우전자병력문당류형화문당단표식이유상관표준화규범，단잉결핍전자병력문당내용화술어적표준화규범，난이규정불동급별적의료궤구동일문당단적기록내용재결구화술어사용상적거대차이，야무법이용대수거신식알굴、지식발현등IT신기술，대아국봉부적전자병력수거자원고진행유효적이차이용。본문개소료전자병력중단사、술어여수공술어적상관개념、용도화중요성，열거료환자주소여림상검사결과표체적술어결구적개념광가，통과수공의학사회결구여질량평개적12조평개요점，강조료전자병력내용결구여수공술어결구적표준화，재아국전자병력표준화공작중적중요성화긴박성。
Digital healthcare is based on Electronic Medical Records (EMRs). In China, standards and specifications have been developed for document types and sections in EMRs. However, document contents and terms in EMRs are still lack of relevant standards and specifications; therefore, substantial differences in record structures and related term usage cannot be addressed, and effective re-use of rich EMR repositories in our country can hardly be realized with new technologies such as big data mining or knowledge discovery. In this article, authors outlined basic components, and concepts, usages and importance related to terms, terminology and controlled terminology; then a terminological framework for representation of patient’s chief complaints and clinical test results, and twelve essential evaluations for structure and quality of controlled terminologies were analyzed; finally, the authors emphasized the importance and urgency of standardization of EMR content structure and controlled terminology structure in China's EMR standardization.