解放军医学院学报2025，Vol.46Issue(5)：492-498,7.DOI:10.12435/j.issn.2095-5227.2025.24062103
军队医院病案首页基本数据集标准研究设计
Research design on standardization of basic dataset for the first page of medical records in military hospitals
摘要
Abstract
Background The medical record front page plays a crucial role in medical quality control,hospital management,scientific research,and medical insurance payment,etc,however,it has not been revised for many years.Objective To develop standardized criteria for basic data sets in the front page of military hospital medical records,establish essential and core data elements,and promote the standardized management of these records.Methods We constructed the required data elements for military hospital medical record headers by basing on the current military hospital medical record headers and the latest national version,through literature reviews,policy analyses,comparative studies,and expert panel consultations.Standardized methodologies were applied to develop the core data set,referencing China's medical record header data element standards and adhering to relevant specifications.Results Based on the 130 data items currently used in the first page of military hospital medical records,28 data items and the data dictionary were revised,26 data items were abolished,and 108 new data items were added,completing the revision of the new first page of military hospital medical records.Based on the data items of the new first page,a basic data set and data element specifications for the first page of military hospital medical records were developed,resulting in 294 data elements and 81 value domain code tables.Conclusion The revision of the new version of military hospital medical record headers and the establishment of standardized criteria for their basic data sets have standardized and objectified data entry processes,minimizing subjective judgments by medical staff.This ensures uniformity and comparability of front-page data across collection,storage,dissemination,and exchange applications,providing robust support for healthcare information system development.It facilitates information sharing,enhances data utilization efficiency,and lays the foundation for evidence-based decision-making in military healthcare management.关键词
军队医院/病案首页/数据集/数据元/标准Key words
military hospital/first page of medical records/dataset/data element/standard分类
医药卫生引用本文复制引用
日火英支,刘丽华,李林,庄倩,邵梦琪..军队医院病案首页基本数据集标准研究设计[J].解放军医学院学报,2025,46(5):492-498,7.基金项目
省部级课题 （）
