CN101944162A - Electronic medical record template system based on XML file and manufacturing method of electronic medical record template - Google Patents
Electronic medical record template system based on XML file and manufacturing method of electronic medical record template Download PDFInfo
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Abstract
The invention relates to an electronic medical record template system based on an XML file and a manufacturing method of an electronic medical record template, belonging to the medical data processing field. The electronic medical record template system comprises a medical record template library, a template analyzer, a knowledge library and a template generator, wherein, the medical record template library is used for storing template elements; the template analyzer is used for analyzing the template element selected by a user into revisable element objects and generating a new paragraph template; the knowledge library is used for revising the paragraph template structure according to a standard medical record template database list structure; and the template generator is used for generating a needed newly established electronic medical record template. The electronic medical record template system of the invention can conveniently call the template elements as required, and can automatically ensure the standardization of the finally generated template, thus being greatly convenient for doctors to operate the medical records of different patients; and in addition, by adopting the system of the invention, the medical record template is in a continuously updated and improved state, so as to adapt to the continuous developmental requirements of the electronic medical record, thus continuously having wider applicability.
Description
Technical field
The present invention relates to a kind of electronic health record template system, especially a kind of electronic health record template system based on XML document that is applied to the electronic health record embedded device also relates to the method that adopts this system to make electronic health record simultaneously, belongs to the medical data process field.
Background technology
Electronic medical record system is to realize that hospital is so that " patient is the core place of " center " as the core of medical industry medical record information system.Following several stages has been experienced in the electronic medical record system construction: in first stage (before 2000), electronic health record only is the electronization of paper case history, and as the case history carrier, the doctor can the typing medical record information with the WORD document, open word file, browse medical record information.These case histories are deposited with the file directory form, lack basic safety management, and after quantity of documents increased, the retrieval of information was very difficult.After recognizing the shortcoming of first generation case history, medical industry begins to build second generation electronic health record infosystem (after 2000), adopt relational database to store and manage medical record information, according to the business norms requirement, after the template segmentation of case history, structured storage is in the lot of data table, and the storage of data and inquiry all have preferable performance like this, and security is also secure.But still have problems, relational database is fit to the fixing business tine of reply structure, and different section office even obstructed doctor's case history template there are differences, need the lot of data table to come the corresponding stored structure, in case change, need to revise many places tables of data definition and relevant application program, maintenance workload is very big.Often need when in addition, case history being inquired about the numerous tables of data of dimension is linked conjunctive query.The programming complexity can't be supported the random inquiry of medical personnel in work and scientific research.Therefore, need could effectively solve the problem of case history content stores and flexible inquiry with a kind of information architecture more flexibly.
Along with case history content coverage rate is more and more wider, structurized content can get more and more, and the structuring degree can continuous refinement.Some structured electronic patient record have adopted tree-like template to preserve medical record data in the world, such as Open SDE (Open SDE is the project of increasing income on the source forge, and the purpose of this research project is in order to realize the structuring typing to case history).But different patients' case history is variant bigger on detail, so the structure of case history tree also presents mobilism trend, need preserve data with dynamic data structure, needs to make it standardization simultaneously.Above-mentioned prior art can't satisfy this demand.
Summary of the invention
The objective of the invention is to: fix, revise complexity, problem difficult in maintenance at existing case history template stores structure, a kind of electronic health record template system based on XML document is proposed, this system not only makes the user revise as required the case history content, and can make revised electronic health record template standardization automatically, thereby break away from the constraint of traditional data list structure, make things convenient for the operation of doctor different patient history; Simultaneously, it is few to take storage space, so that be applicable to embedded device, makes it obtain practical applying.Simultaneously, the present invention also will provide the method for making electronic health record by this system.
For achieving the above object, technical scheme of the present invention is: a kind of electronic health record template system based on XML document, mainly form by case history template base, template parser, knowledge base and template generator;
The case history template base, (described template elements can comprise data with existing unit, assembly, paragraph and template usually in order to the storing template element; Described data element is made of the basic inspection item of corresponding routine, described assembly is made of one group of data element that is mutually related, described paragraph is made up of one group of assembly that is mutually related, and described template is combined by predetermined structure by described data element, assembly, paragraph);
Template parser in order to call XML resolver (MSXML), resolves to revisable element object with user-selected template elements, so that make the user be able to on-the-fly modify described element object in template parser, generates the paragraph template;
Knowledge base in order to storing the database table structure of various predetermined specifications case history templates, and compares one by one by structure and the described list structure with the paragraph template, judges whether standard of paragraph template; For not, then adjust the paragraph formwork structure as judged result, promptly wherein element object constituted and carry out corresponding collocation adjustment, and compare once more, adjust by immediate list structure, until paragraph template compliant, judged result for being;
Template generator, in order to the paragraph template of compliant by calling XSL Designer graphical tools and XML Report assembly, generate required newly-built electronic health record template, show the user, and deposit newly-built electronic health record template in the case history template base.
Adopting system of the present invention to make the electronic health record template may further comprise the steps:
The first step, the template elements of from the case history template base user being selected are added in the template parser;
Second step, call XML resolver resolve to revisable element object with user-selected template elements in the template parser, and the element object after again the user being on-the-fly modified generates new paragraph template;
The 3rd step, previous step paragraph formwork structure that generates and the list structure that is stored in standard case history template in the knowledge base are compared, judge whether standard of paragraph template; , then adjust the paragraph formwork structure, and compare once more, adjust for not as judged result by immediate list structure, until judged result for being;
The 4th step, with the paragraph template of compliant by calling XSL Designer graphical tools and XML Report assembly, generate required newly-built electronic health record template, show the user, and deposit newly-built electronic health record template in the case history template base.
XML (Extensible Markup Language, extend markup language) has the advantages that to pass through the text mode definition data structure of open and self-description, be not only a kind of identifiable language, a kind of especially meta-language that can define the description object structure, thereby the relation between the embodiment data, therefore the present invention is because based on XML, not only can store the case history content of various formizations like a cork, and need not to develop different data structures and application program, and adopt the XML document form to store, can significantly reduce the storage space and the EMS memory occupation space of equipment, very suitable storage space is relatively little, therefore the embedded device that processing speed is relatively slow has desirable practicality.
For the user, electronic health record template system of the present invention is not only changed the shortcoming that the conditional electronic case history can't be revised editor, can call template elements easily as required, and can be automatically by knowledge base, guarantee the last standardization that generates template, remember the template standard thereby need not the doctor, greatly facilitate the operation of doctor different patient history.In addition, behind employing the present invention, the case history template base will be in continual renovation, continuous perfect state, thereby adapt to the demand of the continuous development and change of electronic health record, constantly have more extensive applicability.
Description of drawings
Fig. 1 for the present invention based on case history formwork structure synoptic diagram.
Fig. 2 is for electronic health record template system of the present invention and make the schematic flow sheet of electronic health record template.
Fig. 3 is the process flow diagram of the embodiment of the invention one.
Fig. 4 is the process flow diagram that the embodiment of the invention one generates newly-built electronic health record template.
The electronic health record synoptic diagram that Fig. 5 is generated for Fig. 3 embodiment template generator.
Embodiment
Embodiment one
For making the purpose, technical solutions and advantages of the present invention clearer, will be with following embodiment, and in conjunction with the accompanying drawings, the present invention is described in more detail.
Along with the continuous development of health care science and technology, the content of electronic health record is complicated day by day, wherein generally includes a whole set of medical document and records such as doctor's advice, case history homepage, inspection, check, progress note, operation record, discharge abstract.Based on XML document, the form of case history homepage and inspection can simply be expressed as follows:
<？xml?version＝″1.0″encoding＝″gb2312″？>
＜case history homepage 〉
＜patient essential information 〉
＜bed label〉...＜/bed label 〉
＜patient ID〉...＜/patient ID 〉
＜name〉...＜/name 〉
＜sex〉...＜/sex 〉
......
＜/patient essential information 〉
＜admission date〉...＜/admission date 〉
＜patient diagnosis〉...＜/patient diagnosis 〉
＜AD〉...＜/AD 〉
＜transfer note〉...＜/transfer note 〉
＜operation record〉...＜/operation record 〉
＜DD〉...＜/DD 〉
＜leave hospital the date ...＜/leave hospital the date 〉
......
＜/case history homepage 〉
<？xml?version＝″1.0″encoding＝″gb2312″？>
＜check
＜patient essential information〉...＜/patient essential information 〉
＜inspection item〉...＜/inspection item 〉
＜mail to section office〉...＜/mail to section office 〉
＜the application time〉...＜/the application time 〉
＜symptom〉...＜/symptom 〉
＜sign〉...＜/sign 〉
＜clinical diagnosis〉...＜/clinical diagnosis 〉
＜other diagnosis〉...＜/other diagnosis 〉
＜relevant result of laboratory test〉...＜/relevant result of laboratory test 〉
＜application points for attention〉...＜/application points for attention 〉
＜censorship doctor〉...＜/censorship doctor 〉
......
＜/check 〉
This shows, because the complicacy of electronic health record, and different patients' checking process difference, its electronic health record content also can be different.So the electronic health record template of existing set form can not meet the demands.Present embodiment proposed a kind of form flexibly, the electronic health record template that can change with the case history structure content.
As shown in Figure 1, present embodiment has the multilevel hierarchy of template, paragraph, assembly, data element based on the electronic health record template system of XML, can form a multidimensional medical record information structure flexibly.Wherein, data element is the most basic data cell, represents each common basic inspection item of medical institutions, is exactly data element as fox messages such as leucocyte, haemoglobins.Make up a plurality of data elements and just can form the assembly with professional implication, assembly can refine to information such as every conventional medical inspection, diagnosis (can further make up between the assembly, form the abundanter big assembly of information content).Paragraph is a bulk information carrier of forming template, and it is made up of several assemblies, and paragraph is used for the common aspect of storage of medical records, as patient's routine information, fox message, health check-up information, AD etc.Template then is that the doctor of each section office can select corresponding template, to fill in medical record information by the prior case history pattern well of setting up of the business personnel of medical institutions.
As shown in Figure 2, present embodiment mainly is made up of case history template base, template parser, knowledge base and template generator based on the electronic health record template system of XML document.Wherein, the case history template base is in order to the storing template element.Template parser is in order to call XML resolver (MSXML), by creating the dom tree structure of reflection node logical organization, user-selected template elements is resolved to revisable element object,, generate the paragraph template so that make the user be able in template parser, on-the-fly modify element object.Knowledge base is in order to the database table structure of storage specification case history template, and compares one by one by structure and the list structure with the paragraph template, judges whether standard of paragraph template; As judged result is not, then adjust the paragraph formwork structure by immediate list structure, the structure of revision paragraph template is carried out corresponding collocation adjustment to element object formation wherein, and compare once more, revise ..., until making paragraph template compliant, judged result for being.Template generator generates required newly-built electronic health record template in order to the paragraph template of compliant is passed through XSL Designer graphical tools and XMLReport assembly, shows the user, and deposits newly-built electronic health record template in the case history template base.
Below the concrete generative process of comparatively simple " check " electronic health record template is illustrated.As shown in Figure 3, the making of this electronic health record template may further comprise the steps:
Step 301, when needs are made new electronic health record template, start the electronic health record template program of embedded device, template parser is opened;
Step 302, from the case history template base with needed " check ", " patient's essential information " template, censorship doctor, date of application data element, and " residue is pre-payed gold " and " expense is other " these two data elements add in the template parser;
Step 303, template parser are with the analytical capabilities of call XML resolver (MSXML), and by creating the dom tree structure of reflection node logical organization, it is as follows that above-mentioned loading content is converted to revisable element object:
<？xml?version＝″1.0″encoding＝″gb2312″？> <？xml?version＝″1.0″encoding＝″gb2312″？>
＜patient essential information〉＜check 〉
＜bed label〉＜/bed label〉＜check section office〉＜/check section office 〉
＜patient ID〉＜/patient ID〉＜classification〉＜/classification 〉
＜name〉＜/name〉＜sample〉＜/sample 〉
＜sex〉＜/sex〉＜assay〉＜/assay 〉
＜the age〉＜/age〉＜laboratory physician〉＜/laboratory physician 〉
＜body weight〉＜/body weight〉＜date of inspection〉＜/date of inspection 〉
＜height〉＜/height〉＜/check 〉
＜/patient essential information 〉
<？xml?version＝″1.0″encoding＝″gb2312″？> <？xml?version＝″1.0″encoding＝″gb2312″？>
＜residue is pre-payed gold〉＜/remain and pre-pay gold＜the censorship doctor〉＜/the censorship doctor 〉
<？xml?version＝″1.0″encoding＝″gb2312″？> <？xml?version＝″1.0″encoding＝″gb2312″？>
＜take not＜/expense is other〉＜date of application〉＜/date of application 〉
Step 304, user revise above-mentioned editable element object as required, and it is as follows to form new paragraph template:
<？xml?version＝″1.0″encoding＝″gb2312″？>
＜patient essential information 〉
＜bed label〉＜/bed label 〉
＜patient ID〉＜/patient ID 〉
＜name〉＜/name 〉
＜sex〉＜/sex 〉
＜the age〉＜/age 〉
＜body weight〉＜/body weight 〉
＜height〉＜/height 〉
<？xml?version＝″1.0″encoding＝″gb2312″？>
＜censorship doctor〉＜/the censorship doctor 〉
<？xml?version＝″1.0″encoding＝″gb2312″？>
＜residue is pre-payed gold〉＜/remain and pre-pay gold
<？xml?version＝″1.0″encoding＝″gb2312″？>
＜take not＜/expense is other 〉
＜/patient essential information 〉
＜check 〉
＜check section office〉＜/check section office 〉
＜classification〉＜/classification 〉
＜sample〉＜/sample 〉
＜assay〉＜/assay 〉
＜laboratory physician〉＜/laboratory physician 〉
＜the date of inspection〉＜/date of inspection 〉
<？xml?version＝″1.0″encoding＝″gb2312″？>
＜the date of application〉＜/date of application 〉
＜/check 〉
Step 305, knowledge base compare previous step paragraph formwork structure that generates and the list structure of storing predetermined specifications case history template wherein one by one, find that " censorship doctor " should belong to the content in " check ", now be placed in " patient's essential information ", do not meet standard, automatically adjust the paragraph formwork structure by immediate list structure, make it become the paragraph template of following standard;
<？xml?version＝″1.0″encoding＝″gb2312″？>
＜patient essential information 〉
＜bed label〉＜/bed label 〉
＜patient ID〉＜/patient ID 〉
＜name〉＜/name 〉
＜sex〉＜/sex 〉
＜the age〉＜/age 〉
＜body weight〉＜/body weight 〉
＜height〉＜/height 〉
＜residue is pre-payed gold〉＜/remain and pre-pay gold
＜take not＜/expense is other 〉
＜/patient essential information 〉
＜check 〉
＜check section office〉＜/check section office 〉
＜classification〉＜/classification 〉
＜sample〉＜/sample 〉
＜assay〉＜/assay 〉
＜laboratory physician〉＜/laboratory physician 〉
＜the date of inspection〉＜/date of inspection 〉
＜censorship doctor〉＜/the censorship doctor 〉
＜the date of application〉＜/date of application 〉
＜/check 〉
Step 306, template generator generate the newly-built electronic health record template of standard, show the user, as shown in Figure 5;
Step 307, judge whether user's preview feedback is satisfied with, as satisfaction, then execution in step 308, as dissatisfied, then and with newly-built electronic health record template add template parser automatically to, repeat above-mentioned steps 301;
Step 308 is saved in the case history template base with customer satisfaction system newly-built electronic health record template, finishes the making of this electronic health record template.Embodied hommization so more.
The desirable idiographic flow of above step 306 comprises as shown in Figure 4:
Because XML (Extensible Markup Language, extend markup language) has following characteristics:
1) the self-contained structure of XML document makes the information that exchanges between system to understand mutually, has traditional database and the incomparable superiority of binary file in all many-sides such as the extensibility of data, dirigibility, readability, exchangeability, platform-neutrals;
2) DOM is the structural system of a standard, is used for connecting document and application program;
3) the MSXML resolver allow to load and creates document, and the error message of collecting document obtains operating all information and structure in the document, and document storing in an XML file;
4) DOM offers interface of user and loads, arrives and operate and the serializing XML document, provide simultaneously being stored in the perfect representation of the XML document in the internal memory, and the method for random access entire document;
5) the DOM logical organization that allows application program to provide according to the MSXML resolver is operated the information in the XML document;
Therefore the electronic health record template of present embodiment not only can make things convenient for hospital doctor to write case history greatly, and document format flexibly, to take storage space little, the embedded devices such as electronic health record of similar PDA can be directly applied to, the storage of case history can be under the situation that does not influence the case history content, realized.Along with deepening continuously of practical application, the case history template base will be enriched constantly, thereby adapt to the needs of medical science and technology development.
Claims (6)
1. the electronic health record template system based on XML document is characterized in that comprising: case history template base, template parser, knowledge base and template generator;
Described case history template base is in order to the storing template element;
Described template parser resolves to revisable element object in order to the call XML resolver with user-selected template elements, so that make the user be able to on-the-fly modify described element object in template parser, generates new paragraph template;
Described knowledge base is in order to the database table structure of storing predetermined standard case history template, and compares by structure and the described list structure with the paragraph template, judges whether to conform to; For not, then adjust the paragraph formwork structure as comparative result, revise described paragraph formwork structure, and compare once more by immediate list structure, until judged result for being;
Described template generator in order to the paragraph template of compliant by calling XSLDesigner graphical tools and XML Report assembly, generate required newly-built electronic health record template, show the user, and deposit newly-built electronic health record template in the case history template base.
2. according to the described electronic health record template system based on XML document of claim 1, it is characterized in that: described template elements comprises data with existing unit, assembly, paragraph and template; Described data element is made of the basic inspection item of corresponding routine, described assembly is made of one group of data element that is mutually related, described paragraph is made up of one group of assembly that is mutually related, and described template is combined by predetermined structure by described data element, assembly, paragraph.
3. according to claim 1 or 2 described electronic health record template systems based on XML document, it is characterized in that: described template parser in order to the call XML resolver after, by creating the dom tree structure of reflection node logical organization, user-selected template elements is resolved to revisable element object.
4. adopt that claim 1 is described makes the method for electronic health record template based on the electronic health record template system of XML document, it is characterized in that may further comprise the steps:
The first step, the template elements of from the case history template base user being selected are added in the template parser;
Second step, call XML resolver resolve to revisable element object with user-selected template elements in the template parser, and the element object after again the user being on-the-fly modified generates new paragraph template;
The 3rd step, previous step paragraph formwork structure that generates and the list structure that is stored in standard case history template in the knowledge base are compared, judge whether standard of paragraph template; , then adjust the paragraph formwork structure, and compare once more, adjust for not as judged result by immediate list structure, until judged result for being;
The 4th step, with the paragraph template of compliant by calling XSL Designer graphical tools and XML Report assembly, generate required newly-built electronic health record template, show the user, and deposit newly-built electronic health record template in the case history template base.
5. according to the method for the described making electronic health record of claim 4 template, it is characterized in that: the detailed process in described the 4th step is:
Template generator calls XSL Designer graphical tools, according to the paragraph template of compliant, generates corresponding medical report template;
The paragraph template of described medical report template and standard is exported by xslt processor, obtained meeting the formative newly-built electronic health record template of medical treatment;
Call XML Report assembly, the editor who finishes newly-built electronic health record template visualized objects shows.
6. according to the method for the described making electronic health record of claim 4 template, it is characterized in that: in described the 4th step, before preserving newly-built electronic health record template, also comprise and judge user's preview feedback step of whether being satisfied with, as judged result for being then newly-built electronic health record template to be saved in the case history template base; For not, then turn back to the first step as judged result.
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