CN103593459A - Case history file type-in system and method - Google Patents
Case history file type-in system and method Download PDFInfo
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- 238000012544 monitoring process Methods 0.000 claims abstract description 20
- 238000013479 data entry Methods 0.000 claims description 12
- 238000012360 testing method Methods 0.000 claims description 6
- 238000013481 data capture Methods 0.000 claims description 3
- 238000001514 detection method Methods 0.000 claims description 3
- 238000010586 diagram Methods 0.000 description 6
- 238000003745 diagnosis Methods 0.000 description 5
- 238000012550 audit Methods 0.000 description 4
- 230000008859 change Effects 0.000 description 4
- 230000000391 smoking effect Effects 0.000 description 3
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- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H10/00—ICT specially adapted for the handling or processing of patient-related medical or healthcare data
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Abstract
The invention provides a case history file type-in system which comprises an information analyzing unit, an information monitoring unit and a data type-in unit. The information analyzing unit is used for analyzing stored medical information corresponding to a specific patient, if corresponding information data exist in any medical information item, the medical information item serves as a key word corresponding to the specific patient; the information monitoring unit is used for monitoring input information from a doctor when a case history file of the specific patient is typed in; the data type-in unit is used for replacing the input information with information data corresponding to the matched key word under the condition that the key word matched with the input information exists and typing the information data into the case history file. The invention further discloses a case history file type-in method. By means of the case history file type-in system and method, the input speed of medical information data can be improved and input errors are reduced.
Description
Technical field
The present invention relates to medical information technical field, in particular to a kind of input system of case history document and a kind of input method of case history document.
Background technology
Along with deepening continuously of hospital information, the database that hospital sets up structure storageization for diagnosis and treatment information and other data of patient gradually, shares the important directions that all becomes hospital information between each section office of hospital internal and even across the medical data of hospital.When writing medical document, doctor often needs to have access to and quote a large amount of diagnosis and treatment data messages from other section office or department, information for hospital turns to this data sharing possibility is provided, but how to realize more efficiently data referencing, is still current problem demanding prompt solution.
Summary of the invention
The present invention, just based on the problems referred to above, has proposed a kind of new technical scheme, can improve the input speed to medical information data, reduces the generation of input error.
In view of this, the present invention proposes a kind of input system of case history document, comprise: information analysis unit, for resolving the medical information of having stored corresponding to particular patient, if there is corresponding information data in any one medical information, using described any one medical information as the keyword corresponding to described particular patient; Information monitoring unit, during for case history document in particular patient described in typing, monitoring is from doctor's input message; Data entry element, in the situation that there is the keyword matching with described input message, will replace described input message corresponding to the information data of the described keyword matching, to be input in described case history document.
In this technical scheme, owing to often including the combination of letter, numeral, symbol etc. in information data, easily make mistakes or obscure, and have a strong impact on the input speed of case history document, by to automatically the searching of information data, and replace input message, using as real entry information, thereby contribute to improve input speed, reduce wrong incidence.
In technique scheme, preferably, also comprise: list generation unit, for generating lists of keywords; Association store unit, for carrying out association store to described lists of keywords by each keyword and the reference address mode of corresponding information data; And data capture unit, for when there is the keyword matching with described input message, according to the reference address mode corresponding to this keyword, obtain corresponding information data, for described data entry element, be input to described case history document.
In this technical scheme, by setting up lists of keywords, contribute to realize the accurate monitoring to keyword; Reference address mode by storage corresponding to the information data of keyword, thus without storing separately information data, contribute to reduce storage data volume, avoid data redundancy.
In above-mentioned arbitrary technical scheme, preferably, also comprise: data updating unit, while changing for raw data corresponding to information data when described case history document typing, by corresponding reference address mode, the information data of described typing is upgraded.
In this technical scheme, because original information data corresponding to reference address mode (being raw data) may change, such as finding that the data in certain audit report exist mistake etc., by storage reference address mode, make when raw data changes, can, based on this reference address mode, directly realize the renewal to information data, make it keep synchronizeing with real raw data, guarantee the accuracy of case history document.
In above-mentioned arbitrary technical scheme, preferably, also comprise: information detecting unit, for detection of whether there being the entry information corresponding to described input message in described case history document; Wherein, described data entry element, in the situation that testing result is existence, directly utilizes and replaces described input message corresponding to the information data of the described keyword matching.
In this technical scheme, in the typing mode adopting such as template or other modes, may generate the list that comprises each medical information, need doctor to fill in corresponding information data, backstage is by monitoring in current case history document whether had medical information, if exist, without repeating typing, directly utilize information data to replace input message, help avoid the repetition typing of information.
In above-mentioned arbitrary technical scheme, preferably, described data entry element also for: in testing result, be in non-existent situation, described input message and described information data be input in described case history document in the lump.
In this technical scheme, if there is not the medical information having generated in case history document, input message and the equal typing case history of information data document can be re-entered without doctor, contribute to improve the input speed of case history document.
The invention allows for a kind of input method of case history document, comprise: resolve the medical information of having stored corresponding to particular patient, if there is corresponding information data in any one medical information, using described any one medical information as the keyword corresponding to described particular patient; When the case history document of particular patient described in typing, monitoring is from doctor's input message; When there is the keyword matching with described input message, will replace described input message corresponding to the information data of the described keyword matching, to be input in described case history document.
In this technical scheme, owing to often including the combination of letter, numeral, symbol etc. in information data, easily make mistakes or obscure, and have a strong impact on the input speed of case history document, by to automatically the searching of information data, and replace input message, using as real entry information, thereby contribute to improve input speed, reduce wrong incidence.
In technique scheme, preferably, also comprise: generate lists of keywords; Each keyword and the reference address mode of corresponding information data are carried out to association store to described lists of keywords; And when there is the keyword matching with described input message, according to the reference address mode corresponding to this keyword, obtain corresponding information data.
In this technical scheme, by setting up lists of keywords, contribute to realize the accurate monitoring to keyword; Reference address mode by storage corresponding to the information data of keyword, thus without storing separately information data, contribute to reduce storage data volume, avoid data redundancy.
In above-mentioned arbitrary technical scheme, preferably, also comprise: when in described case history document, the raw data corresponding to information data of typing changed, by corresponding reference address mode, the information data of described typing is upgraded.
In this technical scheme, because original information data corresponding to reference address mode (being raw data) may change, such as finding that the data in certain audit report exist mistake etc., by storage reference address mode, make when raw data changes, can, based on this reference address mode, directly realize the renewal to information data, make it keep synchronizeing with real raw data, guarantee the accuracy of case history document.
In above-mentioned arbitrary technical scheme, preferably, also comprise: detect in described case history document whether have the entry information corresponding to described input message, if exist, directly utilize and replace described input message corresponding to the information data of the described keyword matching.
In this technical scheme, in the typing mode adopting such as template or other modes, may generate the list that comprises each medical information, need doctor to fill in corresponding information data, backstage is by monitoring in current case history document whether had medical information, if exist, without repeating typing, directly utilize information data to replace input message, help avoid the repetition typing of information.
In above-mentioned arbitrary technical scheme, preferably, also comprise: if do not exist, described input message and described information data are input in described case history document in the lump.
In this technical scheme, if there is not the medical information having generated in case history document, input message and the equal typing case history of information data document can be re-entered without doctor, contribute to improve the input speed of case history document.
By above technical scheme, can improve the input speed to medical information data, reduce the generation of input error.
Accompanying drawing explanation
Fig. 1 shows the schematic block diagram of the input system of case history document according to an embodiment of the invention;
Fig. 2 shows the schematic flow diagram of the input method of case history document according to an embodiment of the invention;
Fig. 3 shows the schematic flow diagram of Rapid input case history document according to an embodiment of the invention.
Embodiment
In order more clearly to understand above-mentioned purpose of the present invention, feature and advantage, below in conjunction with the drawings and specific embodiments, the present invention is further described in detail.It should be noted that, in the situation that not conflicting, the application's embodiment and the feature in embodiment can combine mutually.
Set forth in the following description a lot of details so that fully understand the present invention, still, the present invention can also adopt other to be different from other modes described here and implement, and therefore, the present invention is not limited to the restriction of following public specific embodiment.
Fig. 1 shows the schematic block diagram of the input system of case history document according to an embodiment of the invention.
As shown in Figure 1, the input system 100 of case history document according to an embodiment of the invention, comprise: information analysis unit 102, for resolving the medical information of having stored corresponding to particular patient, if there is corresponding information data in any one medical information, using described any one medical information as the keyword corresponding to described particular patient; Information monitoring unit 104, during for case history document in particular patient described in typing, monitoring is from doctor's input message; Data entry element 106, in the situation that there is the keyword matching with described input message, will replace described input message corresponding to the information data of the described keyword matching, to be input in described case history document.
In this technical scheme, owing to often including the combination of letter, numeral, symbol etc. in information data, easily make mistakes or obscure, and have a strong impact on the input speed of case history document, by to automatically the searching of information data, and replace input message, using as real entry information, thereby contribute to improve input speed, reduce wrong incidence.
In technique scheme, preferably, also comprise: list generation unit 108, for generating lists of keywords; Association store unit 110, for carrying out association store to described lists of keywords by each keyword and the reference address mode of corresponding information data; And data capture unit 112, for when there is the keyword matching with described input message, according to the reference address mode corresponding to this keyword, obtain corresponding information data, for described data entry element, be input to described case history document.
In this technical scheme, by setting up lists of keywords, contribute to realize the accurate monitoring to keyword; Reference address mode by storage corresponding to the information data of keyword, thus without storing separately information data, contribute to reduce storage data volume, avoid data redundancy.
In above-mentioned arbitrary technical scheme, preferably, also comprise: data updating unit 114, while changing for raw data corresponding to information data when described case history document typing, by corresponding reference address mode, the information data of described typing is upgraded.
In this technical scheme, because original information data corresponding to reference address mode (being raw data) may change, such as finding that the data in certain audit report exist mistake etc., by storage reference address mode, make when raw data changes, can, based on this reference address mode, directly realize the renewal to information data, make it keep synchronizeing with real raw data, guarantee the accuracy of case history document.
In above-mentioned arbitrary technical scheme, preferably, also comprise: information detecting unit 116, for detection of whether there being the entry information corresponding to described input message in described case history document; Wherein, described data entry element 106, in the situation that testing result is existence, directly utilizes and replaces described input message corresponding to the information data of the described keyword matching.
In this technical scheme, in the typing mode adopting such as template or other modes, may generate the list that comprises each medical information, need doctor to fill in corresponding information data, backstage is by monitoring in current case history document whether had medical information, if exist, without repeating typing, directly utilize information data to replace input message, help avoid the repetition typing of information.
In above-mentioned arbitrary technical scheme, preferably, described data entry element 106 also for: in testing result, be in non-existent situation, described input message and described information data be input in described case history document in the lump.
In this technical scheme, if there is not the medical information having generated in case history document, input message and the equal typing case history of information data document can be re-entered without doctor, contribute to improve the input speed of case history document.
Fig. 2 shows the schematic flow diagram of the input method of case history document according to an embodiment of the invention.
As shown in Figure 2, the input method of case history document according to an embodiment of the invention, comprise: step 202, parsing is corresponding to the medical information of having stored of particular patient, if there is corresponding information data in any one medical information, using described any one medical information as the keyword corresponding to described particular patient; Step 204, when the case history document of particular patient described in typing, monitoring is from doctor's input message; Step 206, when there is the keyword matching with described input message, will replace described input message corresponding to the information data of the described keyword matching, to be input in described case history document.
In this technical scheme, owing to often including the combination of letter, numeral, symbol etc. in information data, easily make mistakes or obscure, and have a strong impact on the input speed of case history document, by to automatically the searching of information data, and replace input message, using as real entry information, thereby contribute to improve input speed, reduce wrong incidence.
In technique scheme, preferably, also comprise: generate lists of keywords; Each keyword and the reference address mode of corresponding information data are carried out to association store to described lists of keywords; And when there is the keyword matching with described input message, according to the reference address mode corresponding to this keyword, obtain corresponding information data.
In this technical scheme, by setting up lists of keywords, contribute to realize the accurate monitoring to keyword; Reference address mode by storage corresponding to the information data of keyword, thus without storing separately information data, contribute to reduce storage data volume, avoid data redundancy.
In above-mentioned arbitrary technical scheme, preferably, also comprise: when in described case history document, the raw data corresponding to information data of typing changed, by corresponding reference address mode, the information data of described typing is upgraded.
In this technical scheme, because original information data corresponding to reference address mode (being raw data) may change, such as finding that the data in certain audit report exist mistake etc., by storage reference address mode, make when raw data changes, can, based on this reference address mode, directly realize the renewal to information data, make it keep synchronizeing with real raw data, guarantee the accuracy of case history document.
In above-mentioned arbitrary technical scheme, preferably, also comprise: detect in described case history document whether have the entry information corresponding to described input message, if exist, directly utilize and replace described input message corresponding to the information data of the described keyword matching.
In this technical scheme, in the typing mode adopting such as template or other modes, may generate the list that comprises each medical information, need doctor to fill in corresponding information data, backstage is by monitoring in current case history document whether had medical information, if exist, without repeating typing, directly utilize information data to replace input message, help avoid the repetition typing of information.
In above-mentioned arbitrary technical scheme, preferably, also comprise: if do not exist, described input message and described information data are input in described case history document in the lump.
In this technical scheme, if there is not the medical information having generated in case history document, input message and the equal typing case history of information data document can be re-entered without doctor, contribute to improve the input speed of case history document.
Fig. 3 shows the schematic flow diagram of Rapid input case history document according to an embodiment of the invention.
As shown in Figure 3, the flow process of Rapid input case history document comprises according to an embodiment of the invention:
Step 302, supposes and need to carry out for certain patient the typing of case history document, and the following medical data relating to, medical information etc., be the data or the information that are associated with this patient.
First, need to, from medical system database, obtain this patient's medical data.This database has comprised all information relevant to patient that in hospital's diagnosis and treatment activity, each section office and department collect or transmit, and not only comprises checking and checking and treatment information, also comprises patient's identity information and other external data relevant with diagnosis and treatment activity etc.Wherein, these information can be preserved with structurized form, the convenient retrieval to the diagnosis and treatment information content.
Then, by the analysis to this patient's medical data, determine keyword, these keywords can be concrete medical informations, such as " smoking history ”,“ main suit ", " blood pressure " etc.
Finally, need to utilize above-mentioned keyword, and corresponding to the information data of these keywords, set up lists of keywords.Wherein, information data refers to corresponding to concrete data this keyword, this patient, and such as for this patient, corresponding " smoking history " may be “10 Nian”,“ main suit " may be " heating " etc.For different patients, corresponding to the information data of same keyword, be also likely different.
By setting up lists of keywords, keyword is associated with concrete information data, thereby is convenient to follow-up query manipulation and obtains this information data.Wherein, can be directly by information data storing in lists of keywords; Also can only in lists of keywords, deposit the reference address mode corresponding to this information data in, can reduce on the one hand the data volume of storage, avoid data redundancy, can guarantee on the other hand the synchronous renewal of information data.
Step 304, determines whether to start the typing to this patient's case history document, if start, enters step 306, otherwise continues to wait for.
Step 306, starts watch-dog, and doctor's input message is carried out to semantic analysis.
Step 308, determines whether the input message that the keyword in existence and lists of keywords matches, if exist, enters step 310, if do not exist, returns to step 306.
Step 310, when there is the keyword of coupling, judges in case history document, whether there be the typing content corresponding with this keyword.In fact, due to existed at present some as provided, comprise can applicable medical information template, make to have comprised these medical informations in case history document, as words such as " smoking history ”,“ main suits ", doctor only needs to fill in the information data corresponding to every medical information; Certainly, also there is the situation that does not have the typing content matching.
Therefore, need to check typing content, thereby when judgement has existed, enter step 312A, otherwise enter step 312B.
Step 312A, the information data of typing association only, to avoid the repetition typing of medical information.
Step 312B, the input message (being medical information) that typing is simultaneously above-mentioned and the information data being associated.
Particularly, for example, an existing fever patient, doctor's typing " main suit " in case history, inserts " generating heat 1 week " automatically; For another example, typing when doctor fills in present illness history " blood pressure ", inserts " Bp136/78mmHg " etc. automatically.
Certainly, above-mentioned input is in the situation that existed corresponding patient medical data to complete; And for outpatient service/emergency physicians, the information that can call may be lacked relatively, such as calling the information such as system of real name patient status information, medical history.
More than be described with reference to the accompanying drawings technical scheme of the present invention, the present invention proposes a kind of input system of case history document and a kind of input method of case history document, can improve the input speed to medical information data, reduced the generation of input error.
The foregoing is only the preferred embodiments of the present invention, be not limited to the present invention, for a person skilled in the art, the present invention can have various modifications and variations.Within the spirit and principles in the present invention all, any modification of doing, be equal to replacement, improvement etc., within all should being included in protection scope of the present invention.
Claims (10)
1. an input system for case history document, is characterized in that, comprising:
Information analysis unit, for resolving the medical information of having stored corresponding to particular patient, if any one medical information exists corresponding information data, using described any one medical information as the keyword corresponding to described particular patient;
Information monitoring unit, during for case history document in particular patient described in typing, monitoring is from doctor's input message;
Data entry element, in the situation that there is the keyword matching with described input message, will replace described input message corresponding to the information data of the described keyword matching, to be input in described case history document.
2. the input system of case history document according to claim 1, is characterized in that, also comprises:
List generation unit, for generating lists of keywords;
Association store unit, for carrying out association store to described lists of keywords by each keyword and the reference address mode of corresponding information data; And
Data capture unit, for when there is the keyword matching with described input message, according to the reference address mode corresponding to this keyword, obtains corresponding information data, for described data entry element, is input to described case history document.
3. the input system of case history document according to claim 2, is characterized in that, also comprises:
Data updating unit, while changing for raw data corresponding to information data when described case history document typing, by corresponding reference address mode, upgrades the information data of described typing.
4. according to the input system of the case history document described in any one in claims 1 to 3, it is characterized in that, also comprise:
Information detecting unit, for detection of whether there being the entry information corresponding to described input message in described case history document;
Wherein, described data entry element, in the situation that testing result is existence, directly utilizes and replaces described input message corresponding to the information data of the described keyword matching.
5. the input system of case history document according to claim 4, is characterized in that, described data entry element also for:
In testing result, be in non-existent situation, described input message and described information data are input in described case history document in the lump.
6. an input method for case history document, is characterized in that, comprising:
Parsing is corresponding to the medical information of having stored of particular patient, if any one medical information exists corresponding information data, using described any one medical information as the keyword corresponding to described particular patient;
When the case history document of particular patient described in typing, monitoring is from doctor's input message;
When there is the keyword matching with described input message, will replace described input message corresponding to the information data of the described keyword matching, to be input in described case history document.
7. the input method of case history document according to claim 6, is characterized in that, also comprises:
Generate lists of keywords;
Each keyword and the reference address mode of corresponding information data are carried out to association store to described lists of keywords; And
When there is the keyword matching with described input message, according to the reference address mode corresponding to this keyword, obtain corresponding information data.
8. the input method of case history document according to claim 7, is characterized in that, also comprises:
When in described case history document, the raw data corresponding to information data of typing changed, by corresponding reference address mode, the information data of described typing is upgraded.
9. according to the input method of the case history document described in any one in claim 6 to 8, it is characterized in that, also comprise:
Detect in described case history document whether have the entry information corresponding to described input message, if exist, directly utilize and replace described input message corresponding to the information data of the described keyword matching.
10. the input method of case history document according to claim 8, is characterized in that, also comprises:
If do not exist, described input message and described information data are input in described case history document in the lump.
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| CN105786934A (en) * | 2014-12-26 | 2016-07-20 | 北大医疗信息技术有限公司 | Method and system for processing medical record document |
| CN106557646A (en) * | 2015-09-28 | 2017-04-05 | 富士通株式会社 | Recording medium, application program active control method and message processing device |
| CN107357811A (en) * | 2017-06-01 | 2017-11-17 | 广西昌成科技有限公司 | A kind of books and reference materials input method and system |
| CN108629198A (en) * | 2017-03-23 | 2018-10-09 | 深圳大学 | A kind of method and medical information input system of medical information typing |
| CN108922579A (en) * | 2017-03-23 | 2018-11-30 | 深圳大学 | A kind of method and medical information input system of medical data typing |
| CN110993046A (en) * | 2019-12-03 | 2020-04-10 | 中国医学科学院北京协和医院 | Rare disease case registration method |
| CN113241185A (en) * | 2021-05-20 | 2021-08-10 | 东华医为科技有限公司 | Method for generating medical text fragment of patient |
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| CN105786934A (en) * | 2014-12-26 | 2016-07-20 | 北大医疗信息技术有限公司 | Method and system for processing medical record document |
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| CN110993046A (en) * | 2019-12-03 | 2020-04-10 | 中国医学科学院北京协和医院 | Rare disease case registration method |
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