Research on Open Structure Data Entry for Electronic Medical Records and Clinical Knowledge Expressive Strategy
- VernacularTitle:电子病历开放式结构化数据采集与临床知识表达策略研究
- Author:
Xichuan ZHENG
;
Yanfeng HU
;
Yunzhen WU
- Publication Type:Journal Article
- Keywords:
structure data entry (SDE);
electronic medical records (EMR);
clinical information system
- From:
Chinese Medical Equipment Journal
2004;0(07):-
- CountryChina
- Language:Chinese
-
Abstract:
Objective To focus on the expressiveness and flexibility of OpenSDE: an application that supports recording of structured narrative data. Methods OpenSDE enabled data entry with (customizable) forms based on trees of medical concepts. The relevant scope for data entry could be tailored per medical domain by construction of a domain-specific tree. OpenSDE was intended for structuring narrative data to make these available for both care and research. Results The OpenSDE application was used at two departments in aspects of radiology, neurology, pediatrics, and child psychiatry. Conclusion OpenSDE is superior to traditional text entry method in aspects of correct and full expression and clinical decision support.
