CAJ | 학술논문

临床信息模型是实现临床数据在异构信息系统中传递而保持语义准确性和完整性的基础，是计算机准确识别和处理临床信息的前提。目前国际上已有的临床信息模型主要有openEHR原型和原型模型、临床元素模型以及ISO 13972详细临床模型等。基于临床信息模型构建结构化临床文档，不仅保证了信息传输中临床数据在语义上的唯一性、一致性和完整性，而且极大地方便了临床信息在医疗服务过程中的首次利用以及在医学科学和政策研究中的二次利用。
림상신식모형시실현림상수거재이구신식계통중전체이보지어의준학성화완정성적기출，시계산궤준학식별화처리림상신식적전제。목전국제상이유적림상신식모형주요유openEHR원형화원형모형、림상원소모형이급ISO 13972상세림상모형등。기우림상신식모형구건결구화림상문당，불부보증료신식전수중림상수거재어의상적유일성、일치성화완정성，이차겁대지방편료림상신식재의료복무과정중적수차이용이급재의학과학화정책연구중적이차이용。
Clinical information model is the foundation of achieving clinical data transmission in heterogeneous information systems while keeping the accuracy and completeness of semantics as well as the premise of computers identifying and dealing with clinical information. At present, the relevant abroad studies on clinical information model and other international standards are openEHR archetype and archetype models, Clinical Element Model and ISO 13972 Detailed Clinical Models, etc. In the application level, we want to build clinical structured documents based on clinical information model supporting for user-computer communications. By this method, we not only ensure the uniqueness, consistency and integrity of clinical data semantics, but also greatly facilitate the primary use of clinical information during the process of medical service and secondary use in medical science and decision-making research.