颅脑创伤结构化病历—数据库的研制

发布时间：2019-01-28 11:54

【摘要】：研究背景及目的：颅脑创伤因高伤残率和高死亡率已成为基础研究和临床研究的热点和重点，但目前临床研究大都缺乏大样本、标准化的数据支撑，导致了研究结果的针对性、适用性与临床需求存在一定的偏差。同时目前颅脑创伤病历大都为非结构化病历系统，信息填写为文本格式，记录描述的随意性大、不规范、缺项多，使相关创伤和其救治信息难以归纳、统计、比较和分析，存在有病例、无数据的现状。本研究依托颅脑创伤病历，病历进行结构化研究，结合颅脑创伤救治路径、救治规范与计算机结构化数据库理论，对颅脑创伤病历信息按照颅脑创伤发生、急救、入院治疗、出院、救治过程等记录信息进行结构化分拆，并与颅脑创伤数据库相适应，初步形成颅脑创伤结构化电子病历－数据库结构，为建立标准、规范颅脑创伤结构化电子病历－数据库系统奠定基础，为开展颅脑创伤临床研究提供数据平台。方法：1、探讨制定科学、合理的颅脑创伤病历内容结构化模块与标准化的表达方式；2、探讨建立颅脑创伤结构化病历和颅脑创伤专科数据库结构的目标，并完成需求分析；3、基于后台数据库平台（SQL Sever）以及.net3.5框架，以C#语言进行软件编写，研发颅脑创伤结构化病历-数据库录入系统软件；4、通过测试录入颅脑损伤住院病历，分析数据库的性能，并初步分析儿童和青少年颅脑创伤救治情况。结果：1、确定了颅脑创伤结构化病历的具体内容、表达方式与说明，实现颅脑创伤病历数据结构模块化，建立结构化病历的内容形式及其表达方式；2、初步形成颅脑创伤结构化电子病历－数据库录入系统结构，编写了颅脑创伤结构化电子病历－数据库录入系统软件；3、通过颅脑创伤救治信息的录入与统计分析,证明了本颅脑创伤结构化病历数据库能较科学、全面地收集颅脑创伤病历资料,具有对颅脑创伤数据进行分析和后期管理的性能,但也存在与实际临床工作对接和收集颅脑创伤资料完整性等方面的困难；4、通过儿童和青少年颅脑创伤资料分析,初步显示儿童颅脑创伤救治的流行病学特点,可以为该年龄段颅脑颅脑创伤预防提供依据。结论：通过对颅脑创伤病历结构化的研究，，证明建立适合颅脑损伤病历结构化电子病历-数据库是可行的；该软件结构合理，内容科学，功能实用，表与表间关系清楚。其操作界面简单方便，能够较好的满足临床颅脑创伤病历资料统计分析，有助于我们掌握颅脑创伤的流行学特征，研究分析影响颅脑创伤发生、急救、转运、院内救治等各个环节的相关因素，为深入研究颅脑创伤的预防与救治提供数据支撑，为颅脑创伤防治决策者提供参考依据，进而提高我国颅脑创伤防、诊、治水平和质量，也为颅脑创伤病历进一步电子化研究打下基础。
[Abstract]:Background and objective: traumatic brain injury has become the focus of basic and clinical research because of its high disability rate and high mortality. However, at present, most of the clinical studies lack of large sample and standardized data support, which leads to the pertinence of the research results. There is a certain deviation between applicability and clinical requirements. At the same time, at present, the medical records of craniocerebral trauma are mostly unstructured medical records, the information is written in the form of text, and the description of the records is arbitrary, irregular and lacking, which makes it difficult to sum up, statistics, compare and analyze the relevant trauma and its cure information. There are cases and no data. This research relies on the craniocerebral trauma medical record, carries on the structural research of the medical record, unifies the craniocerebral trauma rescue path, the treatment standard and the computer structured database theory, according to the craniocerebral trauma medical record information, first aid, admission treatment, In order to establish the standard for establishing the standard, the structured electronic medical record database structure of craniocerebral trauma was initially formed according to the structured separation of the information recorded in the discharge and treatment process and the adaptation of the database to the brain trauma database. To standardize the structured electronic medical record-database system for craniocerebral trauma and provide a data platform for clinical research on traumatic brain injury. Methods: 1) to explore the establishment of scientific and reasonable structural modules and standardized expression methods of the contents of the medical records of craniocerebral trauma, 2) to explore the goal of establishing the structure of structured medical records and specialized databases of craniocerebral trauma, and to complete the requirement analysis; 3. Based on the background database platform (SQL Sever) and .net3.5 framework, the software is written in C # language to develop the software of structured medical record of TBI-database input system. 4. The performance of the database was analyzed by inpatients with craniocerebral injury, and the treatment of traumatic brain injury in children and adolescents was preliminarily analyzed. Results: 1. The concrete content, expression and explanation of the structured medical records of traumatic brain injury were determined, the data structure of the patients with craniocerebral trauma was modularized, and the content form and expression mode of the structured medical records were established. (2) the structure of structured electronic medical record (EMR) -database input system was formed, and the software of structured EMR database input system was compiled. 3. Through the input and statistical analysis of the information about the treatment of craniocerebral trauma, it is proved that the structured medical record database of craniocerebral trauma can collect the data of the medical records of the patients with craniocerebral trauma in a more scientific and comprehensive way. It has the capability of analyzing and managing the data of traumatic brain injury, but it also has difficulties in docking with the actual clinical work and collecting the integrity of the data of traumatic brain injury. 4. By analyzing the data of traumatic brain injury in children and adolescents, the epidemiological characteristics of the treatment of children with traumatic brain injury were preliminarily revealed, which could provide evidence for the prevention of traumatic brain injury in this age group. Conclusion: it is proved that it is feasible to set up a structured electronic medical record database for craniocerebral injury cases by studying the structure of the case history of craniocerebral trauma, the software is reasonable in structure, scientific in content, practical in function, and clear in relation between tables and tables. The operation interface is simple and convenient, which can satisfy the statistical analysis of the clinical traumatic brain injury medical records. It is helpful for us to grasp the epidemiological characteristics of the traumatic brain injury, and to study and analyze the influence on the occurrence, first aid and transportation of the traumatic brain injury. The related factors in hospital treatment and other links provide data support for further study on the prevention and treatment of traumatic brain injury, provide reference basis for decision makers of prevention and treatment of traumatic brain injury, and then improve the level and quality of prevention, diagnosis and treatment of craniocerebral trauma in China. It also lays a foundation for further electronic research on the case history of craniocerebral trauma.
【学位授予单位】：泸州医学院
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R651.15;TP311.13

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