摘要目的 介绍上海市某大型三甲综合性医院建设临床科研信息系统的具体做法.方法 在数据库建设的基础上,进行了住院与手术记录病历、门诊病历以及辅诊报告的结构化设计,并开发了应用终端.结果 开发了一套针对研究型病例、涵盖临床研究各环节的全链路规范化的临床科研信息系统,可以提供个性化定制的结构化数据.结论 该临床科研信息系统为临床医学研究提供了便利,其做法具有一定的借鉴意义.

abstractsObjective To introduce the construction of clinical research information system of a tertiary grade A comprehensive hospital in Shanghai.Methods Based on the database construction,the structured inpatient medical records,surgical records and ancillary diagnostic report are designed and the application terminal is developed.Results A full-link normalized clinical research information system for research-based cases covering all aspects of clinical research is developed,which can provide customized and structured data.Conclusions The clinical research information system provides convenience for clinical medical research,and its practice has certain reference significance.