摘要
在分析梳理面向共享的医学影像结果报告业务流程的基础上,借鉴HL7 CDA R2架构,基于我国卫生信息共享文档编制规范,构建了医学影像结果报告的结构化模板,并与卫生信息数据元目录进行了映射。其中文档头包括主题数据和管理数据,文档体分为临床信息、成像设备信息及过程描述、检查结果信息3个章节及若干条目。
A structured module for medical imaging report was constructed according to the compiling standards for health information sharing files in our country by drawing lesions from the HL7 CDA R2 architecture based on the analysis of sharing-oriented medical imaging report. The structured module was mapped to health information meta-data with subject data and management data included in the file head,with clinical information chapter,imaging equipment information and process description chapter,examination finding information chapter and a number of entries included in the file body.
引文
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