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CLinical Accounting InforMation(CLAIM)是日本开发的电子病历系统与医务结算系统间的数据交换规格。它使用eXtensible Markup Language(XML)作为标记语言,是不同医疗设施之间医疗数据交换规格Medical Markup Language(MML)的从属规格。CLAIM继承了MML2.x的基本结构,目前的版本2.1包括受理、预约、诊疗行为、结算金额等信息的两个模块和9个数据定义表格。考虑到中国现在还没有一个使用XML结构电子病历系统与医务结算系统之间信息的规格,鉴于CLAIM的柔韧性,我们制作了它的汉化版。由于日本的医务结算系统中采用“点数”制度,而中国的医院中没有此概念,另外,处方的书写形式等也与日本不同,所以我们重新制作了这两个模块,并相应的追加和修改了一些表格。CLAIM汉化版的制作将使中国医院的电子病历系统与医务结算系统之间有效而方便地进行数据交换成为可能。
CLinical Accounting InforMation (CLAIM) is a data exchange format developed between Japan’s electronic medical record system and medical settlement system. It uses eXtensible Markup Language (XML) as the markup language and is a dependent specification for the Medical Markup Language (MML), a medical data exchange specification between different medical facilities. CLAIM has inherited the basic structure of MML2.x. The current version 2.1 includes two modules for accepting, reserving, diagnosing and treating, settlement amount and other information and nine data definition tables. Considering that China does not yet have a specification for using XML-structured electronic medical record system and medical settlement system, we made a Chinese version of CLAIM because of its flexibility. Due to the “dot” system used in Japan’s medical settlement system, which is not the case in Chinese hospitals. In addition, prescription forms are also different from those in Japan, so we re-created these two modules and added them accordingly And modified some forms. The production of the CLAIM Chinese version will make it possible to exchange data efficiently and conveniently between the electronic medical record system and the medical settlement system in Chinese hospitals.