CN107945841A - Electronic medical record system based on phonetic entry and the method using system generation electronic health record - Google Patents
Electronic medical record system based on phonetic entry and the method using system generation electronic health record Download PDFInfo
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- 238000000034 method Methods 0.000 title claims abstract description 30
- 238000004519 manufacturing process Methods 0.000 claims abstract description 7
- 208000037265 diseases, disorders, signs and symptoms Diseases 0.000 description 30
- 201000010099 disease Diseases 0.000 description 29
- 230000007774 longterm Effects 0.000 description 21
- 238000011081 inoculation Methods 0.000 description 17
- 230000003449 preventive effect Effects 0.000 description 15
- 210000004369 blood Anatomy 0.000 description 13
- 239000008280 blood Substances 0.000 description 13
- 206010020751 Hypersensitivity Diseases 0.000 description 10
- 230000007815 allergy Effects 0.000 description 10
- 201000004792 malaria Diseases 0.000 description 10
- 201000008827 tuberculosis Diseases 0.000 description 10
- 206010020772 Hypertension Diseases 0.000 description 9
- 208000014674 injury Diseases 0.000 description 9
- 230000008733 trauma Effects 0.000 description 9
- 210000002966 serum Anatomy 0.000 description 8
- 229930182555 Penicillin Natural products 0.000 description 7
- JGSARLDLIJGVTE-MBNYWOFBSA-N Penicillin G Chemical compound N([C@H]1[C@H]2SC([C@@H](N2C1=O)C(O)=O)(C)C)C(=O)CC1=CC=CC=C1 JGSARLDLIJGVTE-MBNYWOFBSA-N 0.000 description 7
- 229940049954 penicillin Drugs 0.000 description 7
- LSQZJLSUYDQPKJ-NJBDSQKTSA-N amoxicillin Chemical compound C1([C@@H](N)C(=O)N[C@H]2[C@H]3SC([C@@H](N3C2=O)C(O)=O)(C)C)=CC=C(O)C=C1 LSQZJLSUYDQPKJ-NJBDSQKTSA-N 0.000 description 6
- 229960003022 amoxicillin Drugs 0.000 description 6
- 208000015181 infectious disease Diseases 0.000 description 6
- LSQZJLSUYDQPKJ-UHFFFAOYSA-N p-Hydroxyampicillin Natural products O=C1N2C(C(O)=O)C(C)(C)SC2C1NC(=O)C(N)C1=CC=C(O)C=C1 LSQZJLSUYDQPKJ-UHFFFAOYSA-N 0.000 description 6
- 238000010586 diagram Methods 0.000 description 5
- 239000003814 drug Substances 0.000 description 5
- 238000011084 recovery Methods 0.000 description 5
- 206010002198 Anaphylactic reaction Diseases 0.000 description 4
- 206010013700 Drug hypersensitivity Diseases 0.000 description 4
- 230000036783 anaphylactic response Effects 0.000 description 4
- 208000003455 anaphylaxis Diseases 0.000 description 4
- 229940079593 drug Drugs 0.000 description 4
- 201000005311 drug allergy Diseases 0.000 description 4
- 208000006454 hepatitis Diseases 0.000 description 4
- 208000017667 Chronic Disease Diseases 0.000 description 3
- 208000026935 allergic disease Diseases 0.000 description 3
- 231100000283 hepatitis Toxicity 0.000 description 3
- 230000008859 change Effects 0.000 description 2
- 230000006870 function Effects 0.000 description 2
- 230000004048 modification Effects 0.000 description 2
- 238000012986 modification Methods 0.000 description 2
- 231100000572 poisoning Toxicity 0.000 description 2
- 230000000607 poisoning effect Effects 0.000 description 2
- 230000009466 transformation Effects 0.000 description 2
- 208000019838 Blood disease Diseases 0.000 description 1
- 206010006458 Bronchitis chronic Diseases 0.000 description 1
- 208000027418 Wounds and injury Diseases 0.000 description 1
- 210000001015 abdomen Anatomy 0.000 description 1
- 230000009471 action Effects 0.000 description 1
- 210000000436 anus Anatomy 0.000 description 1
- 230000009286 beneficial effect Effects 0.000 description 1
- 210000004204 blood vessel Anatomy 0.000 description 1
- 206010006451 bronchitis Diseases 0.000 description 1
- 206010008118 cerebral infarction Diseases 0.000 description 1
- 208000026106 cerebrovascular disease Diseases 0.000 description 1
- 210000000038 chest Anatomy 0.000 description 1
- 208000007451 chronic bronchitis Diseases 0.000 description 1
- 238000010276 construction Methods 0.000 description 1
- 206010012601 diabetes mellitus Diseases 0.000 description 1
- 235000013399 edible fruits Nutrition 0.000 description 1
- 238000005516 engineering process Methods 0.000 description 1
- 210000001508 eye Anatomy 0.000 description 1
- 235000013305 food Nutrition 0.000 description 1
- 210000003128 head Anatomy 0.000 description 1
- 210000002216 heart Anatomy 0.000 description 1
- 208000019622 heart disease Diseases 0.000 description 1
- 208000014951 hematologic disease Diseases 0.000 description 1
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Classifications
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- G—PHYSICS
- G10—MUSICAL INSTRUMENTS; ACOUSTICS
- G10L—SPEECH ANALYSIS TECHNIQUES OR SPEECH SYNTHESIS; SPEECH RECOGNITION; SPEECH OR VOICE PROCESSING TECHNIQUES; SPEECH OR AUDIO CODING OR DECODING
- G10L15/00—Speech recognition
- G10L15/26—Speech to text systems
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- Engineering & Computer Science (AREA)
- Computational Linguistics (AREA)
- Health & Medical Sciences (AREA)
- Audiology, Speech & Language Pathology (AREA)
- Human Computer Interaction (AREA)
- Physics & Mathematics (AREA)
- Acoustics & Sound (AREA)
- Multimedia (AREA)
- Medical Treatment And Welfare Office Work (AREA)
Abstract
A kind of method the invention discloses electronic medical record system based on phonetic entry and using system generation electronic health record, wherein, the electronic medical record system based on phonetic entry includes microphone and processor, and microphone is used to input voice for user；Processor is used to be positioned lteral data to the predeterminated position in default electronic health record template according to speech production or selection lteral data.The method of system generation electronic health record includes selecting the predeterminated position in electronic health record template by phonetic entry；Lteral data is inputted or selected by predeterminated position of the phonetic entry in electronic health record template；User realizes the structuring of electronic health record and reaches the convenience of typing according to generating structure electronic health record is identified after template phonetic entry.
Description
Technical field
The present invention relates to a kind of electronic medical record system and the method for generating electronic health record, and in particular to one kind is based on voice
The electronic medical record system of input and the method using system generation electronic health record.
Background technology
Electronic health record has gradually been popularized in the use of hospital, and structured electronic patient record, which has, to be found to tie from motion tracking
Fruit, carries out the advantages that accurate disease collect statistics and efficient case history are retrieved, and most hospitals are using passing through mouse-keyboard group
Close, click edit structure content, supplement the mode of unstructured content, generating structure, semi-structured electronic health record, but this
Kind input mode takes, is cumbersome.In addition, the Partial Hospitals voice typing electronics by the way of plug-in phonitic entry method
Case history, but this mode generate be pure natural language case history, the advantages of lost structured electronic patient record.
The content of the invention
A kind of electronic medical record system based on phonetic entry, including：
Microphone, for inputting voice for user；
Processor, for being positioned lteral data to default electronic health record mould according to speech production or selection lteral data
Predeterminated position in plate.
Further, the electronic medical record system based on phonetic entry further includes：
First trigger, for supplying user's operation so that processor is in station-keeping mode；
When processor is in station-keeping mode, processor is according to pre- in the voice selecting electronic health record template of microphone input
If position.
Further, the electronic medical record system based on phonetic entry further includes：
Second trigger, for supplying user's operation so that processor is in input pattern；
When processor is in input pattern, processor is filled to electronic health record template according to the speech production of microphone input
In predeterminated position lteral data.
Further, the electronic medical record system based on phonetic entry further includes：
Second trigger, for supplying user's operation so that processor is in input pattern；
When processor is in input pattern, processor is filled to electronic health record template according to the voice selecting of microphone input
In predeterminated position lteral data.
Further, the electronic medical record system based on phonetic entry further includes：
Memory, for storing the electronic health record and pass through phonetic entry that electronic health record template generated by phonetic entry
The electronic health record of generation.
A kind of electronic health record generation method based on phonetic entry, includes the following steps：
Predeterminated position in electronic health record template is selected by phonetic entry；
Lteral data is inputted or selected by predeterminated position of the phonetic entry in electronic health record template.
Further, the electronic health record generation method based on phonetic entry includes the following steps：Give birth to electronic health record template
As electronic health record；Electronic health record is stored as the e-file of specified format to server.
Further, the electronic health record generation method based on phonetic entry includes the following steps：Select the use of phonetic entry
Way is to determine that the phonetic entry that will carry out is for selecting predeterminated position in electronic health record template or in electronic health record mould
Predeterminated position input or selection lteral data in plate.
Further, the electronic health record generation method based on phonetic entry includes the following steps：For in electronic health record template
Predeterminated position rule is set, and proofreaded according to rule to inputting to the text information of predeterminated position.
Further, the electronic health record generation method based on phonetic entry includes the following steps：Selected by phonetic entry
Select after the predeterminated position in electronic health record template in the predeterminated position display content template.
The invention has the beneficial effects that：
Phonitic entry method is incorporated into electronic medical record system by the present invention, with reference to the convenience of phonetic entry, is provided at the same time
Structured electronic patient record template.User realizes electronic health record according to generating structure electronic health record is identified after template phonetic entry
Structuring and reach the convenience of typing.
Brief description of the drawings
Fig. 1 is the schematic block diagram of a preferred embodiment of the electronic medical record system based on phonetic entry of the present invention；
The step of Fig. 2 is a preferred embodiment of the electronic health record generation method based on phonetic entry of the present invention is illustrated
Block diagram；
Fig. 3 is the screenshotss schematic diagram of the electronic stencil of a default paragraph " past medical history "；
Fig. 4 is that the electronic health record that the electronic stencil of paragraph " past medical history " generates after phonetic entry is preset shown in Fig. 3
Screenshotss schematic diagram；
Fig. 5 is screenshotss schematic diagram of the electronic health record under manual modification state shown in Fig. 4.
Embodiment
As shown in Figure 1, a kind of electronic medical record system based on phonetic entry, including：Microphone, processor, the first triggering
Device and the second trigger.
Wherein, microphone is used to input voice for user；Processor, for being incited somebody to action according to speech production or selection lteral data
Lteral data is positioned to the predeterminated position in default electronic health record template.First trigger is used for for user's operation so that processing
Device is in station-keeping mode.When processor is in station-keeping mode, processor is according to the voice selecting electronic health record mould of microphone input
Predeterminated position in plate.Second trigger is used for for user's operation so that processor is in input pattern；Processor is in input
During pattern, processor is filled to the word number of the predeterminated position in electronic health record template according to the speech production of microphone input
According to.Alternatively, when processor is in input pattern, processor is filled to electronic health record template according to the voice selecting of microphone input
In predeterminated position lteral data.
In addition, memory can also be included by being somebody's turn to do the electronic medical record system based on phonetic entry, memory is used to store electronics
The electronic health record that medical record templates are generated by phonetic entry and the electronic health record generated by phonetic entry.
In addition, display can also be included by being somebody's turn to do the electronic medical record system based on phonetic entry, for showing electronic health record.
Above microphone, processor, the first trigger, the second trigger, memory and electronic health record can be integrated in
One special equipment and then access network or server system.
Alternatively, microphone, the first trigger, the second trigger can be integrated into a similar meeting and talked about
The device of cylinder, makes it be formed with computer and connects, using the processor of computer, memory and display are as the place in system
Manage device, memory and display.
Certainly, present system, should not be since the various pieces in present system be by difference also in other configurations mode
The part of device forms and limits the scope of the invention.
With reference to shown in Fig. 2, the electronic health record generation method based on phonetic entry of the present invention is introduced below by way of Fig. 2.
In general, case history can according to type be divided into patient medical history, emergency record, inpatient cases, with complicated disease of being in hospital
Exemplified by going through, inpatient cases can be divided into admission records, progress note, informed consent form etc..
By taking admission records as an example, personal information, main suit, present illness history, past medical history, personal history, family history, general feelings can be divided into
Condition, sub-mucosal, lymph node, head, eye, ear, nose, oral cavity, neck, chest, lungs, heart, blood vessel, belly, anus
Door and the part such as rectum and generator, backbone, four limbs, nervous system, for convenience of explanation, by electronic health record in the present invention
These parts are defined as " default paragraph ".In electronic health record, these default paragraphs exist in the form of electronic stencil.
During generation electronic health record in the past, it is defeated that user generally requires first to select default paragraph then to proceed by
Enter.
In the method for the invention, can be positioned by phonetic entry to default paragraph.For example using hardware above side
During case, user can by by next function button, opening the pattern of a setting, in this mode, phonetic entry it is interior
Appearance is for selecting the default paragraph specified, for example at this time, then processor will be from system for user speech input " past medical history "
The electronic stencil of default paragraph " past medical history " is recalled, and is presented to user.
Then, user presses another function button, opens the pattern of another setting, in this mode, phonetic entry
Content be default in default paragraph to need the content filled for filling.
It is of course also possible to use a button goes switching both of which, and not necessarily to use two independent buttons.
As shown in figure 3, the electronic stencil of the default paragraph " past medical history " called includes two parts, one of part
For the part outside square brackets in fixed part, such as Fig. 3, another part is needs the part filled, i.e., within square brackets
Part, the part that these needs are filled is defined as " structuring element ".Structuring element can be understood as in electronic health record
Some specific medical terminologys are marked using a kind of label symbol, for example in the example shown in Fig. 3, are included by side
Number form marked, and it is encoded, codomain scope is set, each attribute such as read-only, unsuppressible-suppression is set.
For these medical terminologys being marked, date type, value type (such as in [numerical value] year), simple can be divided into
Option type (comprising one or more options, such as denying [hepatitis]), complicated option type (are nested with structuring member in option
Plain option as [in [numerical value] before year with " [chronic disease title please be input]), free text type (such as [disease unrelated with this disease
History]).Structuring element in the template is marked with [].
As an example, it is as follows if generation template is gone with the form of xml：
<Text>Past medical history：</Text>
<Field AllowEmpty=" 0 " Code=" 11329-0 " ID=" 2015070251832 " Name=" is previously
History ">
<Text>Patient goes over constitution</Text>
<Field ID=" 1000000419.2.20110512145308.5518 " Name=" physical condition " Type="
1"/>
<Text>.History of disease：</Text>
<Field AllowEmpty=" 0 " ID=" 1000000031.3.20110512150622.9347 " Name=was " both
Toward 2 " MaxValue=" -1 " of medical history " Type=">
<Text>In</Text>
<Field AllowEmpty=" 0 " ID=" 1000000416.1.20110512145308.3567 " Name=" numbers
Value " ValueType=" 1 " MaxValue=" 0 " MinValue=" 0 " CodeSystemName=" LONIC "/>
<Text>Suffered from before year "</Text>
<Field AllowEmpty=" 0 " ID=" 1000000974.1.20110512145305.9727 " Name=" bases
This input frame " CodeSystemName=" LONIC ">
<Text>It please input chronic disease title</Text>
</Field>
<Text>", take</Text>
<Field AllowEmpty=" 0 " ID=" 1000000974.1.20110512145305.9727 " Name=" bases
This input frame " CodeSystemName=" LONIC ">
<Text>It please input nomenclature of drug</Text>
</Field>
<Text>, it is existing</Text>
<Field AllowEmpty=" 0 " ID=" 1000000684.2.20110512145411.2246 " Name=" is controlled
Treat result " Type=" 1 " CodeSystemName=" LONIC ">
<Text>Recovery from illness</Text>
</Field>
</Field>
<Text>.Infect medical history：</Text>
<Field AllowEmpty=" 0 " ID=" 1000000030.3.20110512150623.6773 " Name=" is passed
2 " MaxValue=" -1 " of history of catching an illness " Type=">
<Text>Deny</Text>
<Field AllowEmpty=" 0 " ID=" 1000000450.2.20110512145322.5619 " Name=" is passed
Catch an illness 1 " MaxValue=" -1 " of history-multiselect " Type=">
<Text>Hepatitis</Text>
</Field>
<Text>Deng infection medical history</Text>
</Field>
<Text>.History of preventive inoculation：</Text>
<Field AllowEmpty=" 0 " ID=" 1000000013.3.20110512150623.5311 " Name=" is pre-
Anti- inoculation history " Type=" 2 " MaxValue=" -1 ">
<Text>History of preventive inoculation is unknown</Text>
</Field>
<Text>.Allergies：</Text>
<Field ID=" 1000000016.3.20110512150624.0196 " Name=" drug allergy history " Type
=" 2 ">
<Text>Deny medicine, food hypersenstivity history</Text>
</Field>
<Text>.History of operation：</Text>
<Field AllowEmpty=" 0 " ID=" 1000000014.3.20110512150625.1177 " Name=" hands
2 " MaxValue=" -1 " of art history " Type=">
<Text>Deny history of operation</Text>
</Field>
<Text>.Trauma history：</Text>
<Field AllowEmpty=" 0 " ID=" 1000000017.3.20110512150625.7654 " Name=" is outer
Hinder 2 " MaxValue=" -1 " of history " Type=">
<Text>Deny trauma history</Text>
</Field>
<Text>.Blood transfusion history：</Text>
<Field AllowEmpty=" 0 " ID=" 1000000015.3.20110512150626.1111 " Name=is " defeated
2 " MaxValue=" -1 " of blood history " Type=">
<Text>Deny history of transfusing blood</Text>
</Field>
<Text>.Poisoning history：</Text>
<Field ID=" 1000000198.3.20110512150627.5505 " Name=" poisoning history " Type=" 2 ">
<Text>Deny history of being poisoned</Text>
</Field>
<Text>.Long-term administration：</Text>
<Field ID=" ADMINISTRATOR.3.20170418111341.5700 " Name=" long-term administration " Type
=" 2 ">
<Text>Patient denies there is long-term administration history</Text>
</Field>
<Text>.Possible dependence producing drug：</Text>
<Field ID=" ADMINISTRATOR.3.20170418111601.7203 " Name=" possible dependence producing drug "
Type=" 2 "/>
<Text>.Medical history unrelated with this disease：</Text>
<Field ID=" ADMINISTRATOR.1.20170418112008.7904 " Name=" diseases unrelated with this disease
History "/>
<Text>, it is other：</Text>
After default paragraph is selected by phonetic entry, user can be visually observed that electronics disease as shown in Figure 3
The form of expression of template is gone through, is then prompted according to template, typing voice.But there are multiple structurings in electronic health record template
Element, user when inputting speech pattern specific to be which structuring element really need solve.
As one way in which, user is still used for the mode of phonetic entry, is specifying default paragraph and then secondary
Input voice selects a predeterminated position in default paragraph, then to select a structuring element in default paragraph
Switch mode is inputted or edited for the structuring element of the predeterminated position again.
For example user presses first button, phonetic entry " past medical history " and then system by the preset mode of " past medical history "
User is presented to, user presses the first button again, and phonetic entry " blood transfusion history ", then presses second button again, defeated again at this time
The voice entered is used for interstitital texture element.
More than as mode, can realize data input and electronic health record generation, in order to improve with upper type efficiency with
And the frequency for thinking operation is reduced, following scheme can also be used.
I.e. after user selects default paragraph, user can start to proceed by phonetic entry, language according to template content
The content elder generation Direct Recognition of sound input is natural language text.
Then, keyword of the processor in natural language text judges element type, such as the narration in past medical history
In, user speech inputs in the natural language text of generation the text information for including " history of operation ", and processor " will perform the operation
History " is used as keyword, and corresponding textual portions are judged, such key definition is structuring keyword, then
Judge that content of text belongs to that structuring element in default paragraph according to structuring keyword.
For example date type is judged as according to the structuring keyword such as " date of birth ", " admission time ", " record time "
When, it is rational date range to natural text error correction, and do date type structuring processing.
According to " height ", " before _ year " when structuring keyword is judged as value type, to natural character this according to key
Word constrains number range, inputs numerical value to corresponding single-bit correction according to user, such as input is " height：170 meters " it is corrected to " body
It is high：170 centimetres " and do value type structuring processing.
When being judged as simple option type according to keyword, best match is made in corresponding option for text, is selected
Best match simultaneously does structuring processing.Such as " patient goes over constitution [physical condition] " in template, physical condition is according to " patient goes over
Constitution " keyword is judged as simple option type, and matching entries have " body is good for ", " body is good ", " body is general ", " body
Difference "；Above-mentioned option and the input highest option of matching degree are selected, carries out structuring processing.Matching degree matches phase by simple text
Like degree processing, if input item is identical with multiple option matching degrees and is highest, selected with consistent algorithm (such as option cis-position)
One of them option is corrected processing；If input item is 0 with option matching degree, error flag is made.
When being judged as complicated option type according to keyword, best match is made in the complexity option scope to text,
The text in the option is continued at the same time to judge type based on structuring keyword, carries out structuring operation.Such as " disease in template
History：[suffered from " [chronic disease title please be input] " before year in [numerical value], take and [nomenclature of drug please be input], existing [recovery from illness]] ".
Weather text is judged for complicated option type by " history of disease ", option is " no history of disease ", " having history of disease ",
"None", " unknown "；Above-mentioned option and the input highest option of matching degree are selected, carries out structuring processing.Matching degree is by simple text
The processing of word matching similarity, if input item is identical with multiple option matching degrees and is highest, with consistent algorithm, (such as option is suitable
Position) select one of them option and be corrected processing；If input item is 0 with option matching degree, error flag is made.
When being judged as free text type according to keyword, do not dealt with for text, make structural markup.
When whole sentence is without keyword, it is judged as unstructured input, text is not processed, is not marked.
Mode in this way is completed to be corrected according to the type of structuring element.
Assuming that doctor is that " it is fine that patient goes over body according to identification text after template voice typing.History of disease：Deny feeling
Emit, the history of disease such as hypertension.Infect medical history：Tuberculosis was suffered from before 3 years, malaria was suffered from before 2 years, is now fully recovered.History of preventive inoculation：No
In detail.Allergies：Readme is to penicillin, serum anaphylaxis.History of operation：Deny history of operation.Trauma history：Deny trauma history.Blood transfusion history：It is no
Give up blood history.Long-term administration history：Long-term use of Amoxicillin.”
Structuring processing is as follows：For " it is fine that patient goes over body ", " patient goes over " is that " physical condition " structuring is closed
Keyword；" physical condition " is simple option type, and option is " body is good for ", " body is good ", " body is general ", " body is poor "；
" body is fine " input is consistent with " body is good ", " body is general " structuring option matching degree, according to option sequential selection " body
Body is good ", therefore export result " patient goes over [body is good] ".
For " history of disease：Deny the history of disease such as hypertension ", " history of disease " is " history of disease " structuring keyword；" disease
History " is complicated option type, and option is " no history of disease ", " having history of disease ", "None", " unknown "；" deny the diseases such as hypertension
History " is matched with " no history of disease ", therefore whole sentence adds structural markup.Structure is carried out to " denying high blood pressure disease history etc. " text again
Change operation：" denying " is " no history of disease " keyword, and option is " hypertension ", " diabetes ", " ephritis ", " blood disease ", " hat
Worry ", " heart disease ", " chronic bronchitis ", " cerebral infarction ", " flu " make error flag, " hypertension " without match options
Matched with " hypertension ", " waiting history of disease " is determined as unstructured content, exports result " history of disease without match options：[deny
The history of disease such as flu, [hypertension]] ".
For " infecting medical history：Tuberculosis was suffered from before 3 years, malaria was suffered from before 2 years, is now fully recovered ", " infection medical history " is " to infect
Medical history " structuring keyword；" infection medical history " is complicated option type, option is " free from infection history ", " having infection medical history ",
"None", " unknown "；" tuberculosis was suffered from before 3 years, malaria was suffered from before 2 years." matched with " having infection medical history ", therefore whole sentence adds structure
Change mark.Structuring operation is carried out to " tuberculosis being suffered from before 3 years, malaria was suffered from before 2 years " text again：" before 3 years " are numerical value class
Type structuring keyword, makees " three " scope correction and structural markup；" suffering from " is simple option type structure keyword,
Option has " hepatitis ", " tuberculosis ", " malaria ", and " tuberculosis " is matched with " tuberculosis "；" before 2 years " are crucial for value type structuring
Word, makees " two " scope correction and structural markup；" suffering from " is simple option type structure keyword, and option has " liver
Inflammation ", " tuberculosis ", " malaria ", " malaria " is matched with " malaria "." existing " is simple types structuring keyword, and option, which has, " fullys recover from an illness
More ", " delay ", " not being cured ", " improvement ", " not controlling ", " recovery from illness " are matched with " recovery from illness ", and final output result " infects medical history：[[3]
[tuberculosis] is suffered from before year, [malaria] was suffered from before [2] year, existing [recovery from illness]] ".
For " history of preventive inoculation：History of preventive inoculation is unclear ", " history of preventive inoculation " is that " history of preventive inoculation " structuring is closed
Keyword；" history of preventive inoculation " is complicated option type, option is " no history of preventive inoculation ", " having history of preventive inoculation ", " with locality
Progress ", " unknown "；" history of preventive inoculation is unclear " and " history of preventive inoculation is unknown " matching degree highest, therefore export " immunization campaign
History：[history of preventive inoculation is unknown] ".
For " allergies：Readme is to penicillin, serum anaphylaxis ", " allergies " are " allergies " structuring keyword；" mistake
Quick history " is complicated option type, and option is " having drug allergy history ", " medicine-less allergy history ", " unknown "；" readme is to mould
Element, serum anaphylaxis " is matched with " having drug allergy history ", does structural markup.Again to " readme is to penicillin, serum anaphylaxis " text
Carry out structuring operation：" readme to " is simple types keyword, and option is " penicillin ", the anaphylactogen such as " pollen ", " mould
Element " is matched with " penicillin ", and " serum " is matched with " serum ", exports " allergies：[to [penicillin] [serum] allergy] ".
For " history of operation：Deny history of operation ", " history of operation " is " history of operation " structuring keyword；" history of operation " is complexity
Option type, option are " no history of operation ", " having history of operation ", " unknown "；" denying history of operation " matches with " no history of operation ", defeated
Go out " history of operation：[denying [history of operation]] "." trauma history：Deny trauma history " similarly output be " trauma history：[deny wound
History]] "." blood transfusion history：Deny history of transfusing blood " similarly export as " [blood transfusion history：Deny [blood transfusion history]] ".
For " long-term administration：Long-term use of Amoxicillin ", " long-term administration " are " long-term administration " structuring keyword；
" long-term administration " is complicated option type, and option is " having long-term administration history ", " no long-term administration history ", " unknown "；" long-term clothes
With Amoxicillin " matched with " having long-term administration history ", do structural markup." long-term use of Amoxicillin " text is tied again
Structureization operates：" long-term use " is free text class keywords, so retaining " Amoxicillin " text, whole sentence structural mark
Note, exports as " long-term administration:[long-term use of Amoxicillin] ".
Either artificial or system, method of the invention can finally position the text information that phonetic entry identifies to pre-
If the predeterminated position of paragraph.
As shown in figure 5, the method for the present invention can modify the electronic health record Jing Guo phonetic entry.User can appoint
Meaning modification output content word, structuring substitute word in identifying and store into corresponding construction classification.User can double-click knot
, there is counter structure class option, makes replacement at this time in word in structureization mark.
In addition, the save button that user can be provided by clicking in system interface, then system can be read in edit box
Content, be converted into structuring XML electronic health records, then upload to support XML storage relational database in (SQLServer,
Oracle etc.).
Transformation result is as follows：
<Text>Past medical history：</Text>
<Field AllowEmpty=" 0 " Code=" 11329-0 " ID=" 2015070251832 " Name=" is previously
History ">
<Text>Patient goes over constitution</Text>
<Field ID=" 1000000419.2.20110512145308.5518 " Name=" physical condition "
Type=" 1 ">
<Text>Body is good</Text>
</Field>
<Text>.History of disease：</Text>
<Field AllowEmpty=" 0 " ID=" 1000000031.3.20110512150622.9347 " Name=was " both
Toward 2 " MaxValue=" -1 " of medical history " Type=">
<Text>Deny catching a cold</Text>
<Field AllowEmpty=" 0 " ID=" 1000000451.2.20110512145312.4134 " Name=was " both
Toward 1 " MaxValue=" -1 " of medical history " Type=">
<Text>" hypertension "</Text>
</Field>
<Text>Etc. medical history</Text>
</Field>
<Text>.Infect medical history：</Text>
<Field AllowEmpty=" 0 " ID=" 1000000030.3.20110512150623.6773 " Name=" is passed
2 " MaxValue=" -1 " of history of catching an illness " Type=">
<Field AllowEmpty=" 0 " ID=" 1000000416.1.20110512145308.3567 " Name=" numbers
It is worth " ValueType=" 1 " MaxValue=" 0 " MinValue=" 0 " CodeSystemName=" LONIC ">
<Text>3</Text>
</Field>
<Text>Suffered from before year "</Text>
<Field AllowEmpty=" 0 " ID=" 1000000450.2.20110512145322.5619 " Name=" is passed
Catch an illness history-multiselect " Type=" 1 " CodeSystemName=" LONIC ">
<Text>Tuberculosis</Text>
</Field>
<Text>",</Text>
<Field AllowEmpty=" 0 " ID=" 1000000416.1.20110512145308.3567 " Name=" numbers
It is worth " ValueType=" 1 " MaxValue=" 0 " MinValue=" 0 " CodeSystemName=" LONIC ">
<Text>2</Text>
</Field>
<Text>Suffered from before year "</Text>
<Field AllowEmpty=" 0 " ID=" 1000000450.2.20110512145322.5619 " Name=" is passed
Catch an illness history-multiselect " Type=" 1 " CodeSystemName=" LONIC ">
<Text>Malaria</Text>
</Field>
<Text>”</Text>
</Field>
<Text>.History of preventive inoculation：</Text>
<Field AllowEmpty=" 0 " ID=" 1000000013.3.20110512150623.5311 " Name=" is pre-
Anti- inoculation history " Type=" 2 " MaxValue=" -1 ">
<Text>History of preventive inoculation is unknown</Text>
</Field>
<Text>.Allergies：</Text>
<Field ID=" 1000000016.3.20110512150624.0196 " Name=" drug allergy history " Type
=" 2 ">
<Text>Private prosecution pair</Text>
<Field AllowEmpty=" 0 " ID=" 1000000449.2.20110512145325.1967 " Name=" mistakes
Min Shi-multiselect " Type=" 1 " CodeSystemName=" LONIC ">
<Text>Penicillin, serum</Text>
</Field>
<Text>Allergy</Text>
</Field>
<Text>.History of operation：</Text>
<Field AllowEmpty=" 0 " ID=" 1000000014.3.20110512150625.1177 " Name=" hands
2 " MaxValue=" -1 " of art history " Type=">
<Text>Deny history of operation</Text>
</Field>
<Text>.Trauma history：</Text>
<Field AllowEmpty=" 0 " ID=" 1000000017.3.20110512150625.7654 " Name=" is outer
Hinder 2 " MaxValue=" -1 " of history " Type=">
<Text>Deny trauma history</Text>
</Field>
<Text>.Blood transfusion history：</Text>
<Field AllowEmpty=" 0 " ID=" 1000000015.3.20110512150626.1111 " Name=is " defeated
2 " MaxValue=" -1 " of blood history " Type=">
<Text>Deny history of transfusing blood</Text>
</Field>
<Text>.Long-term administration：</Text>
<Field ID=" ADMINISTRATOR.3.20170418111341.5700 " Name=" long-term administration " Type
=" 2 ">
<Text>Long-term use of A Moxilin</Text>
The method for summarizing the above, the method for the present invention step summary are：
Predeterminated position in electronic health record template is selected by phonetic entry；
In the predeterminated position display content template after the predeterminated position during electronic health record template is selected by phonetic entry；
Lteral data is inputted or selected by predeterminated position of the phonetic entry in electronic health record template；
The purposes of selection phonetic entry is for selecting in electronic health record template to determine the phonetic entry that will be carried out
Predeterminated position or the predeterminated position input in electronic health record template or selection lteral data；
Rule is set for the predeterminated position in electronic health record template, and the word inputted to predeterminated position is believed according to rule
Breath is proofreaded；
It is electronic health record to make electronic health record template generation；The e-file that electronic health record is stored as to specified format extremely services
Device.
The basic principles, main features and advantages of the invention have been shown and described above.The technical staff of the industry should
Understand, the invention is not limited in any way for above-described embodiment, all to be obtained by the way of equivalent substitution or equivalent transformation
Technical solution, all falls within protection scope of the present invention.
Claims (10)
- A kind of 1. electronic medical record system based on phonetic entry, it is characterised in that：The electronic health record system based on phonetic entry System includes：Microphone, for inputting voice for user；Processor, for being positioned lteral data into default electronic health record template according to speech production or selection lteral data Predeterminated position.
- 2. the electronic medical record system according to claim 1 based on phonetic entry, it is characterised in that：It is described to be based on 1 sound of language The electronic medical record system of input further includes：First trigger, for supplying user's operation so that the processor is in station-keeping mode；When the processor is in station-keeping mode, the processor is according to the voice selecting electronic health record mould of the microphone input Predeterminated position in plate.
- 3. the electronic medical record system according to claim 2 based on phonetic entry, it is characterised in that：It is described defeated based on voice The electronic medical record system entered further includes：Second trigger, for supplying user's operation so that the processor is in input pattern；When the processor is in input pattern, the processor is filled to electronics according to the speech production of the microphone input The lteral data of predeterminated position in medical record templates.
- 4. the electronic medical record system according to claim 2 based on phonetic entry, it is characterised in that：It is described defeated based on voice The electronic medical record system entered further includes：Second trigger, for supplying user's operation so that the processor is in input pattern；When the processor is in input pattern, the processor is filled to electronics according to the voice selecting of the microphone input The lteral data of predeterminated position in medical record templates.
- 5. the electronic medical record system according to any one of claims 1 to 4, based on phonetic entry, it is characterised in that：Institute The electronic medical record system based on phonetic entry is stated to further include：Memory, for storing electronic health record that electronic health record template generated by phonetic entry and being generated by phonetic entry Electronic health record.
- A kind of 6. electronic health record generation method based on phonetic entry, it is characterised in that：The electronic health record generation method based on phonetic entry includes the following steps：Predeterminated position in electronic health record template is selected by phonetic entry；Lteral data is inputted or selected by predeterminated position of the phonetic entry in electronic health record template.
- 7. the electronic health record generation method according to claim 6 based on phonetic entry, it is characterised in that：The electronic health record generation method based on phonetic entry includes the following steps：It is electronic health record to make the electronic health record template generation；The electronic health record is stored as the e-file of specified format to server.
- 8. the electronic health record generation method according to claim 6 based on phonetic entry, it is characterised in that：Electronic health record generation method based on phonetic entry includes the following steps：The purposes of selection phonetic entry is default in electronic health record template for selecting with the definite phonetic entry that will be carried out Position or the predeterminated position input in electronic health record template or selection lteral data.
- 9. the electronic health record generation method according to claim 6 based on phonetic entry, it is characterised in that：The electronic health record generation method based on phonetic entry includes the following steps：For the predeterminated position in the electronic health record template, rule is set, and according to rule to inputting to the text of the predeterminated position Word information is proofreaded.
- 10. the electronic health record generation method according to claim 6 based on phonetic entry, it is characterised in that：The electronic health record generation method based on phonetic entry includes the following steps：In the predeterminated position display content template after the predeterminated position during electronic health record template is selected by phonetic entry.
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| WO2019024692A1 (en) * | 2017-08-02 | 2019-02-07 | 深圳壹账通智能科技有限公司 | Speech input method and device, computer equipment and storage medium |
| CN110767282A (en) * | 2019-10-30 | 2020-02-07 | 苏州思必驰信息科技有限公司 | Health record generation method and device and computer readable storage medium |
| CN110931089A (en) * | 2018-08-30 | 2020-03-27 | 希尔-罗姆服务公司 | System and method for EMR vital sign recording |
| CN112232042A (en) * | 2020-09-08 | 2021-01-15 | 广州金域医学检验中心有限公司 | Material taking information input method and device, computer equipment and storage medium |
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