Research on terminology standardization, and the structuring and digitalization of medical records in Zhuang medicine: a case study of Zhendong Zhuang Medicine Orthopedics
壮医病案的术语规范与结构化数字化研究——以《振东壮医骨科》为例

摘要

为推动壮医病案的规范整理与现代化利用，促进民族医学临床经验的系统传承与数字转化，本文以吴振东主编的《振东壮医骨科》为研究对象，选取第三章“风湿类疾病（发旺）验案”，系统分析病案结构、术语使用和信息表达方式等方面的特征与不足。研究发现，《振东壮医骨科》病案在诊疗思路与疗效记录方面具有较高的经验价值，但存在结构要素不完整、术语体系混用、表述经验化和信息难以直接结构化处理等问题，制约了病案信息的共享、分析与研究。基于上述分析，本文提出以病案结构标准化、术语体系规范化和数据模型构建为核心的结构化数字化实现路径，为壮医病案数据库建设及壮医药现代化研究提供参考。

Abstract

To promote the standardized organization and modern utilization of Zhuang medicine medical records, and to facilitate the systematic inheritance and digital transformation of clinical experience in ethnic medicine, this study takes Zhendong Zhuang Medicine Orthopedics, edited by Wu Zhendong, as the research object. The third chapter, “Case Records of Rheumatic Diseases (Fa Wang),” is selected for in-depth analysis, focusing on the characteristics and shortcomings of case record structure, terminology usage, and information presentation. The study finds that while the medical records in Zhendong Zhuang Medicine Orthopedics possess high experiential value in terms of diagnostic and therapeutic thinking as well as treatment outcome documentation, they commonly suffer from problems such as incomplete structural elements, mixed use of terminology systems, experience-based expressions, and difficulties in direct structured data processing. These problems limit the sharing, analysis, and further research of medical record information. Based on the above analysis, this paper proposes a structured and digital pathway centered on the standardization of medical record structures, normalization of terminology systems, and construction of data models, providing references for the development of Zhuang medicine medical record databases and the modernization research of Zhuang medicine.