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目前，我正在为一家拥有门诊和住院诊所的大型医院实施 HL7 CDA。为了减少平均咨询时间，咨询医生使用电子表格。表格必须彻底形式化（理想情况下需要最少的键盘输入）。

在实践中，最简单的正式咨询说明表格似乎包含不少于 40-50 个输入字段。

例如，普通耳鼻喉科医生的“体检”栏目包括以下子栏目：外鼻、内鼻、咽喉、喉、气管；请注意，鼻子是对称的，每个器官都可以用 10-15 个特征来描述——因此我有一个包含大约 100 个输入字段的输入表单。将 HL7 CDA 咨询说明规范定义的其他必需部分添加到此表格（访问原因、疾病史、问题、药物） - 您有大约 150 个字段。因此，我的 HL7 CDA 3 级文档正文应包含相同数量的 [观察] 元素。

在一个普通的住院病例中，医生最多可以登记 10-100 个文件。每个文档包含 20-100-200 个有意义的参数。总共：~10000 个参数。

在住院病例结束时，医生应创建一份摘要文件，该文件从之前登记的其他文件中收集数据。在这一点上，我觉得我误解了 HL7 CDA 规范。一个人不能轻易地操作 10000 个参数。您能否给我一个建议（或示例）关于如何设计符合人体工程学的用户表单，让医生创建一个简短的摘要文档？

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You're not misunderstanding the basic premise, but on the issue of providing a "human-readable display, don't try to associate independent display values for each tiny observation.

CDA allows you to provide <text> nodes as part of each segment, which are generally HTML data that will be displayed when read by a human being. For encounters with lots of observations, retain the parsed observations in the CDA, but each individual observation value should have a null <text> value (one that doesn't display to the provider). Instead, provide an HTML/readable version of all the observations in a higher-level parent node (so you'd have all of the observations about the "Nose" in a single HTML table stored inside the <text> node of the segment titled "<title>Nose</title>". Or - even better - you could even go to an even higher-level segment than this, and store a full HTML version of the entire observation section of the SOAP note along with the general practitioner's notes in the <text> node associated with the encounter <section>.

Long story short: formally retain all the values in the CDA, but consolidate all of these observations into a single human-readable display (HTML) in the <text> node of a higher level node. This will allow a nice-looking display for the provider, but retain all of the codified data for machines.

Have a look at Blue Button Plus for some CDA examples that might make the whole issue a little clearer.

于 2013-04-05T19:05:38.557 回答