【作者】 王茜；

【导师】 周拴龙；

【作者基本信息】 郑州大学 ， 图书馆学， 2016， 硕士

【摘要】 电子病历是记录病人的完整的医疗记录,随着信息技术和医疗信息化的发展,电子病历逐渐取代纸质病历,成为医疗信息共享的核心。电子病历在方便医院健康管理的同时,也为医学研究和临床诊断提供了大量的临床数据。既可避免纸质病历使用中繁琐乏味的工作,又可帮助医生进行智能决策,为用户诊断提供有效参考意见,减少医疗事故造成的不必要的损失。医学诊断本身的不确定性给医疗诊断增加了难度,然而随着目前医学临床分科的不断细化,医生知识的狭窄使得难以将病人作为一个有机整体加以周全考虑,无疑又给临床诊断增加了风险。传统医疗已经无法满足信息时代世界各国人民对健康的需求,医疗信息化发展迫切需要从信息服务转向智力服务。以电子病历为基础,构建基于电子病历的诊断系统,可以充分利用已有电子病历中的诊疗信息,降低医生的误诊率,提高医生的决策效率,为医疗诊断决策提供强大智力支持。因此基于电子病历的医疗诊断辅助系统的研究成为医疗信息化发展的研究焦点。本文第一部分对研究背景和意义进行陈述,接着对国内外基于电子病历的医疗诊断辅助系统的研究状况进行陈述,分析开发此系统的意义和价值。第二部分介绍系统设计中所需使用的理论基础和关键技术,包括电子病历理论、医学信息分类以及重点要介绍的案例推理技术理论。第三部分重点结合本系统,阐述案例推理技术在本系统中的具体应用,对系统进行详细设计,重点进行数据库的设计以及案例检索阶段的设计。第四部分在.NET环境下实现基于电子病历的医疗诊断辅助系统的设计实现,对主要开发工具以及技术进行阐述,进行系统实现效果图的展示。更多还原

【Abstract】 Electronic medical record is the patient complete medical record. With the development of information technology and medical informatization, electronic medical record gradually replaces paper record, and become the core of the medical information sharing.It’s not only convenient for hospital health management, but also for medical research and clinical diagnosis with providing a wealth clinical of data. It can not only help hospitals avoid the tedious work of the paper medical record but also help the doctors do intelligent decision making and give effective references to the patients, so it can reduce the unnecessary loss caused by medical accidents.The uncertainty of medical diagnosis increases the difficulty of medical treatment. However, with the current medicine clinical specialties continue to refine and the doctor’s narrow knowledge, the doctors can not regard a patient as an organic whole to consider comprehensively. There is no doubt that it increases the risk of clinical diagnosis. Traditional medical treatment has been unable to meet the demand for health of the people all over the world. Medical informatization urgently need the transition from information service to the intelligence service. Constructing a diagnosis system on the basis of electronic medical record can take full advantage of of the diagnosis and treatment information of the existing electronic medical record, reduce the doctor’s misdiagnosis rate, improve the decision-making efficiency of doctors, and provide strong intellectual support for the medical diagnostic decision. So the study on medical diagnosis aided system based on electronic medical record is the research focus of Medical informatization.In this paper, the first part states the background and meaning of this research, then states the research status domestic and overseas of the medical diagnosis aided system based on electronic medical record with its development meaning and value. The second part describes the theoretical basis and key technology of the system design needed, including electronic medical record theory, medical information classification and case-based reasoning technology. The next part combine case-based reasoning technology with this system, describing its specific application and it’s detailed design. The system design focuses on the database and case retrieval design. The fourth part is mainly for system implementation, with the presentation of the main development tools, and shows the system implementation effect figures.更多还原