CN109949889A - A kind of Nursing Electronic medical records system - Google Patents
A kind of Nursing Electronic medical records system Download PDFInfo
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- CN109949889A CN109949889A CN201910247904.7A CN201910247904A CN109949889A CN 109949889 A CN109949889 A CN 109949889A CN 201910247904 A CN201910247904 A CN 201910247904A CN 109949889 A CN109949889 A CN 109949889A
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Abstract
The invention discloses a kind of Nursing Electronic medical records systems, comprising: data center, authority management module, user management module, template management module, GUI module, multiple client module, clock sync server, for providing clock synchronous service for multiple client module；Multiple client module, it is also used to user's login, write nursing history, it is attached to after the nursing history write from clock sync server acquisition time stamp and generates medical record information to be uploaded, and the digital signature of medical record information to be uploaded is generated using the private key of user, medical record information and digital signature to be uploaded are uploaded to data center, so as to data center's preservation.
Description
Technical field
The present invention relates to the technical fields of hospital information management system, and in particular to a kind of Nursing Electronic medical records system.
Background technique
With the development of hospital information system, the various information systems in hospital are also more and more, but do not have usually specially
The nursing system of door records the medical record information of nursing, is usually that handwriting mode is taken to be recorded on paper, this looking into
When readding record, efficiency is especially low.
Therefore need to provide a kind of Nursing Electronic medical records system, to nursing history information computerization be recorded, after being
Search inquiry provide according to support.In Nursing Electronic medical records system, nursing history information is most important, is generally not allowed him
People arbitrarily modifies, and to provide foundation in subsequent medical complaint or malpractice, therefore just needs to prevent medical record information
It distorts and provides support with safe transmission.
Summary of the invention
(1) the technical issues of solving
For the deficiency of existing hospital information system, the main object of the present invention first is that Nursing Electronic medical records system,
To record nursing history information computerization, provide for later search inquiry according to support.In Nursing Electronic medical records system,
Its nursing history information is most important, other people is generally not allowed arbitrarily to modify, so as in subsequent medical complaint or malpractice
Middle offer foundation, therefore just need to provide support to the anti-tamper and safe transmission of medical record information.
(2) technical solution and beneficial effect
The object above present invention is achieved by the following technical programs:
A kind of Nursing Electronic medical records system, comprising:
Data center, stores the Nursing Electronic case history of multiple patients, and each Nursing Electronic case history includes patient's name, patient
Mark, symptom description information, nursing information, wherein nursing information includes operating time, operator, action name and operation knot
Fruit；
Authority management module, for distributing setting corresponding permission for user grouping and to every group of user, permission includes
It checks, modify, creating, the power of examination and approval, distribution also sets up the corresponding permission object of permission when permission is arranged；
User management module, for distributing account for system user and corresponding permission being arranged in user's registration；
Template management module, for creating, storing or modifying multiple nursing history templates,
GUI module for providing visualized operation interface for user, including shows to user and adjusts from template management module
Medical record templates out, guidance user fill in medical record templates；It is also used to show the Nursing Electronic case history that search obtains to user；
Multiple client module for user by multiple client Module registers or login system, and passes through GUI module
The GUI of transmitting passes to multiple client module and is shown, and receives user and pass through the GUI information inputted and be transmitted to corresponding
Template management module, data center, authority management module and template management module；
Clock sync server, for providing clock synchronous service for multiple client module；
Multiple client module is also used to user's login, writes nursing history, stabs from clock sync server acquisition time
Medical record information to be uploaded is generated after being attached to the nursing history write, and generates case history to be uploaded using the private key of user and believes
Medical record information and digital signature to be uploaded are uploaded to data center by the digital signature of breath, so as to data center's preservation.
A method of nursing history being uploaded using above system, is included the following steps:
1), when system is implemented, user account and corresponding permission are set for all nursing stafves；
2), nursing staff passes through the client modules login account that each ward or office treatment is arranged in, and selects to write
Nursing history, system obtains the permission of login user by authority management module at this time, and judges whether user writes nursing
The permission of case history, if there is then allowing user's operation, if it is not, prompting user and terminating；Nursing is write in user's selection
After case history, system is shown in client mould by GUI module by one default nursing history template of template management module selection
Block, user may be selected replace other nursing history templates, then user fill in it is needing user to fill in nursing history template or
Projects of selection, projects include patient's name, Patient identification, symptom description information, nursing information, operating time, operation
The nursing information of member, action name and operating result, after user selects to save nursing history, client modules will nurse disease
It goes through template and information that user fills in is sent to data center and saves.
Wherein, client modules the information for filling in nursing history template and user before transmitting, carry out anti-usurp
Changed handling and addition timestamp information processing, implement step are as follows:
After user selects to save case history, it includes patient's name, Patient identification, symptom description letter that client modules, which obtain,
The medical record information of breath, nursing information, client modules obtain present system time stamp from clock sync server, and case history is believed
Breath and present system time stamp are grouped together into medical record information to be uploaded, using the private key of user to case history to be uploaded
Information carries out hash and corresponding digital signature data is calculated, and then client modules are by the medical record information and signature of upload
Data are uploaded to data center together, and data center is saved as Nursing Electronic case history；
And/or
After user selects to save case history, it includes patient's name, Patient identification, symptom description letter that client modules, which obtain,
The medical record information of breath, nursing information, client modules obtain present system time stamp from clock sync server, and case history is believed
Breath and present system time stamp are grouped together into medical record information to be uploaded, then from patient's name, Patient identification, symptom
A part of information is selected in description information, nursing information, using the private key of user to a part of information and system selected
Timestamp carries out hash and corresponding digital signature data is calculated, and then client modules are by the medical record information and number of upload
Word signed data is uploaded to data center together, and data center is saved as Nursing Electronic case history.
Signed data is generated using combination:
Hashed value is calculated to all fields that medical record information includes using MD5 mode first, obtains the first digital signature；
Then hashed value is calculated to the significant field selected in all fields for including in medical record information using SHA-1,
Obtain the second digital signature；
When uploading, medical record information, the first digital signature and the second digital signature that will be uploaded transmit client together
To data center.
Data center verifies every the medical record information that fixed time period stores it or data center is according to tool
There is the instruction of the user of verifying authorization to verify, and by verify unacceptable medical record information notify to highest permission user or
It is responsible for the user of management specially.
When carrying out anti-tamper verifying, data center verifies signature using public key:
The first digital signature is verified using MD5 mode first, if verifying does not pass through, judges that current medical record information is complete
Property verifying do not pass through, that is, illustrate that case history is tampered；If the verification passes, then the second digital signature is verified using SHA-1 mode, such as
Fruit verifying does not pass through, then judges that current medical record information integrity verification does not pass through, that is, illustrate that case history is tampered, if the verification passes
Digital signature authentication is just judged to pass through.
Said combination verification mode can also first verify the second digital signature, then verify the first digital signature.
Further, medical record information allows user to modify when there is mistake, but when changing case history, needs to test
The permission of card operator allows to change if permission has change permission, and records change personnel and change content, with
And the change time；If not changing permission, refuse to change.
The application can reach following technical effect:
Nursing Electronic medical records system provided by the present application can record nursing history information computerization, search to be later
Rope inquiry is provided according to support；Meanwhile, it is capable to which Nursing Electronic medical record information is avoided to be tampered, its safety is provided；Further
Ground further improves the safety of Nursing Electronic medical record information by combined signature technology, while signature verification also can be improved
Speed.
Detailed description of the invention
Fig. 1 is Nursing Electronic medical records system structural schematic diagram of the present invention
Specific embodiment
Following will be combined with the drawings in the embodiments of the present invention, and technical solution in the embodiment of the present invention carries out clear, complete
Site preparation description, it is clear that described embodiments are only a part of the embodiments of the present invention, instead of all the embodiments.It is based on
Embodiment in the present invention, it is obtained by those of ordinary skill in the art without making creative efforts every other
Embodiment shall fall within the protection scope of the present invention.
A kind of Nursing Electronic medical records system, comprising:
Data center, stores the Nursing Electronic case history of multiple patients, and each Nursing Electronic case history includes patient's name, identity
Number (or passport No., social security card number), symptom description information, nursing information are demonstrate,proved, wherein nursing information includes operating time, operation
Member, action name and operating result；
Authority management module, for distributing setting corresponding permission for user grouping and to every group of user, permission includes
It checks, modify, creating, the power of examination and approval, distribution also sets up the corresponding permission object of permission when permission is arranged；
User management module, for distributing account for system user and corresponding permission being arranged in user's registration；
Template management module, for creating, storing or modifying multiple nursing history templates,
GUI module for providing visualized operation interface for user, including shows to user and adjusts from template management module
Medical record templates out, guidance user fill in medical record templates；It is also used to show the Nursing Electronic case history that search obtains to user；
Multiple client module for user by multiple client Module registers or login system, and passes through GUI module
The GUI of transmitting passes to multiple client module and is shown, and receives user and pass through the GUI information inputted and be transmitted to corresponding
Template management module, data center, authority management module and template management module.
Clock sync server, for providing clock synchronous service for multiple client module.
Firstly, being respectively provided with account and corresponding permission when system is implemented for all nursing stafves.
When nursing staff carries out routine work, the client modules by the way that each ward or office treatment is arranged in log in account
Number, and select to write nursing history, system judges whether user has the permission for writing nursing history at this time, if there is then allowing to use
Family operation, if it is not, prompt user；After nursing history is write in user's selection, system is selected by template management module
One default nursing history template, and client modules are shown in by GUI module, other nursing diseases of replacement may be selected in user at this time
Template is gone through, then user fills in projects that need user to fill in nursing history template or selection, mainly includes patient last name
Name, identification card number (or passport No., social security card number), symptom description information, nursing information, operating time, operator, action name
And the nursing information of operating result, after user selects to save nursing history, client modules by nursing history template and
The information that user fills in is sent to data center and saves.
Wherein, client modules the information for filling in nursing history template and user before transmitting, need to carry out
Anti-tamper processing and addition timestamp information processing.By two step process, avoid nursing history by other people distort can
Can, thus guarantee the integrality of case history, to transfer original medical record information when subsequent medical is complained or malpractice judges,
Reliable evidence is provided, or establishes accurately tracking for patient medical record in subsequent and traces to the source information, to provide reliable warp
Test information.
Specifically, anti-tamper processing and addition timestamp information processing mainly include the following two kinds mode:
Mode one, using digital signature technology, after user selects to save case history, client modules acquisition patient's name,
The medical record informations such as identification card number (or passport No., social security card number), symptom description information, nursing information, client modules are from clock
Sync server obtains present system time stamp, and medical record information and present system time stamp are grouped together into and to be uploaded
Medical record information, using user private key to the medical record information to be uploaded carry out hash corresponding digital signature number is calculated
According to, then the medical record information of upload and signed data are uploaded to data center by client modules together, data center by its
Save as Nursing Electronic case history.
But above-mentioned mode one is all directly to calculate the hash value of all data, computationally intensive, in signature verification
It is corresponding to need complicated calculating step.
Mode two, part number signature technology, after user selects to save case history, client modules acquisition patient's name,
The medical record informations such as identification card number (or passport No., social security card number), symptom description information, nursing information, client modules are from clock
Sync server obtains present system time stamp, and medical record information and present system time stamp are grouped together into and to be uploaded
Medical record information, then from patient's name, identification card number (or passport No., social security card number), symptom description information, nursing information
A part of information is selected as hash and calculates basis, when using the private key of user to a part of information and system to be selected
Between stamp carry out hash corresponding digital signature data be calculated, then client modules are by the medical record information and number of upload
Signed data is uploaded to data center together, and data center is saved as Nursing Electronic case history.
Aforesaid way two only selects significant data field and carries out hash calculating, reduces the calculating of hash by this method
Amount.And wherein selection mode can carry out random selection or machine learning mode selects, random selection mode is to be randomly selected
A part of field in field is stated, machine learning mode is selected as the field conduct for counting by historical data and being easy to be tampered
The field of selection, and the above-mentioned field selected also is notified data center, advice method can be in the case history that will be uploaded
When information and digital signature data are uploaded to data center together, the field selected is subjected to special marking.
In order to further strengthen safety, can combine above two mode use, i.e., generated using combination
Signed data:
All fields that usage mode a pair of medical record information includes first calculate hashed value, obtain the first digital signature,
Middle calculating hashed value mode is to use MD5 mode；
Then usage mode two calculates hashed value to the significant field selected in all fields for including in medical record information,
The second digital signature is obtained, wherein calculating hashed value mode is to use SHA-1 mode；
For last client when uploading, medical record information, the first digital signature and the second digital signature that will be uploaded are together
Send data center to.
Data center provides anti-tamper authentication function, can carry out every the medical record information that fixed time period stores it
Verifying, and unacceptable medical record information will be verified and notify the user to highest permission or be responsible for the user of management specially；In data
The heart can also execute the anti-tamper authentication function according to the instruction triggers of the user with verifying authorization.Wherein, anti-tamper test is carried out
When card, data center verifies signature using public key, when generating signed data using combination, data center
Signature verification is carried out using combined authentication mode accordingly, it may be assumed that
The first digital signature is verified using MD5 mode first, if verifying does not pass through, judges that current medical record information is complete
Property verifying do not pass through, that is, illustrate that case history is tampered；If the verification passes, then the second digital signature is verified using SHA-1 mode, such as
Fruit verifying does not pass through, then judges that current medical record information integrity verification does not pass through, that is, illustrate that case history is tampered, if the verification passes
Digital signature authentication is just judged to pass through.
Said combination verification mode can also first verify the second digital signature, then verify the first digital signature, because of the second number
Word signature calculation speed is fast, once the second digital signature authentication does not pass through, can be judged as that verifying does not pass through, no longer need to judge
First digital signature, improves verifying speed.
By the above-mentioned means, only just judging number after the first digital signature and the second digital signature are verified
Word signature verification passes through, and avoids the risk that MD5 or SHA-1 one way in which is knocked decoding, while can also improve verifying
Speed.
Further, medical record information allows user to modify when there is mistake, but when changing case history, needs to test
The permission of card operator allows to change if permission has change permission, and records change personnel and change content, with
And the change time；If not changing permission, refuse to change.
It should be appreciated that interchangeable other embodiments of the invention are apparent for those skilled in the art
's.However, the scope of the present invention be not limited to more than described embodiment, but only by claim of the invention
Given content limits.
Claims (8)
1. a kind of Nursing Electronic medical records system, comprising:
Data center, stores the Nursing Electronic case history of multiple patients, and each Nursing Electronic case history includes patient's name, Huan Zhebiao
Know, symptom description information, nursing information, wherein nursing information includes operating time, operator, action name and operation knot
Fruit；
Authority management module, for distributing for user grouping and to every group of user corresponding permission being arranged, permission include check,
Modification, creation, the power of examination and approval, distribution also set up the corresponding permission object of permission when permission is arranged；
User management module, for distributing account for system user and corresponding permission being arranged in user's registration；
Template management module, for creating, storing or modifying multiple nursing history templates,
GUI module is recalled including showing to user from template management module for providing visualized operation interface for user
Medical record templates, guidance user fill in medical record templates；It is also used to show the Nursing Electronic case history that search obtains to user；
Multiple client module for user by multiple client Module registers or login system, and is transmitted by GUI module
GUI pass to multiple client module and shown, and receive user and by the GUI information inputted and be transmitted to corresponding mould
Board management module, data center, authority management module and template management module；
Clock sync server, for providing clock synchronous service for multiple client module；
Multiple client module is also used to user's login, writes nursing history, additional from clock sync server acquisition time stamp
Medical record information to be uploaded is generated after to the nursing history write, and medical record information to be uploaded is generated using the private key of user
Medical record information and digital signature to be uploaded are uploaded to data center by digital signature, so as to data center's preservation.
2. system according to claim 1, which is characterized in that the private key of user is stored in U-shield.
3. a kind of method for carrying out nursing history upload using the described in any item systems of claim 1-2, includes the following steps:
1), when system is implemented, user account and corresponding permission are set for all nursing stafves；
2), nursing staff passes through the client modules login account that each ward or office treatment is arranged in, and selects to write nursing
Case history, system obtains the permission of login user by authority management module at this time, and judges whether user writes nursing history
Permission, if there is then allowing user's operation, if it is not, prompt and terminates at user；Nursing history is write in user's selection
Afterwards, system is by one default nursing history template of template management module selection, and is shown in client modules by GUI module,
User may be selected to replace other nursing history templates, and then user fills in need user to fill in nursing history template or selection
Projects, projects include patient's name, Patient identification, symptom description information, nursing information, operating time, operator, behaviour
The nursing information for making title and operating result, after user selects to save nursing history, client modules are by nursing history mould
The information that plate and user fill in is sent to data center and saves.
4. according to the method described in claim 3, it is characterized in that, client modules are filled out by nursing history template and user
The information write before transmitting, carries out anti-tamper processing and addition timestamp information processing, implements step are as follows:
After user selects to save case history, it includes patient's name, Patient identification, symptom description information, shield that client modules, which obtain,
Manage the medical record information of information, client modules obtain present system time stamp from clock sync server, and by medical record information and
Present system time stamp is grouped together into medical record information to be uploaded, using the private key of user to medical record information to be uploaded
It carries out hash and corresponding digital signature data is calculated, then client modules are by the medical record information and signed data of upload
It is uploaded to data center together, data center is saved as Nursing Electronic case history；
And/or
After user selects to save case history, it includes patient's name, Patient identification, symptom description information, shield that client modules, which obtain,
Manage the medical record information of information, client modules obtain present system time stamp from clock sync server, and by medical record information and
Present system time stamp is grouped together into medical record information to be uploaded, then from patient's name, Patient identification, symptom description
A part of information is selected in information, nursing information, using the private key of user to a part of information and system time selected
Stamp carries out hash and corresponding digital signature data is calculated, and then client modules sign the medical record information of upload and number
Name data are uploaded to data center together, and data center is saved as Nursing Electronic case history.
5. according to the method described in claim 4, it is characterized in that, generating signed data using combination:
Hashed value is calculated to all fields that medical record information includes using MD5 mode first, obtains the first digital signature；
Then hashed value is calculated to the significant field selected in all fields for including in medical record information using SHA-1, obtained
Second digital signature；
For client when uploading, medical record information, the first digital signature and the second digital signature that will be uploaded send number to together
According to center.
6. according to the method described in claim 4, it is characterized in that, the disease that data center stores it every fixed time period
It goes through that information is verified or data center verifies according to the instruction of user with verifying authorization, and will verify obstructed
The medical record information crossed notifies the user to highest permission or the user for being responsible for management specially.
7. according to the method described in claim 5, it is characterized in that, data center uses public key pair when carrying out anti-tamper verifying
Signature is verified:
The first digital signature is verified using MD5 mode first, if verifying does not pass through, judges that current medical record information integrality is tested
Card does not pass through, that is, illustrates that case history is tampered；If the verification passes, then the second digital signature is verified using SHA-1 mode, if tested
Card does not pass through, then judges that current medical record information integrity verification does not pass through, that is, illustrate that case history is tampered, just can if the verification passes
Judge that digital signature authentication passes through.
8. according to the method described in claim 3, it is characterized in that, medical record information exist mistake when, allow user modify,
But when changing case history, the permission of verification operation personnel is needed, if permission has change permission, allows to change, and is recorded more
Change personnel and change content, and change time；If not changing permission, refuse to change.
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| CN201910247904.7A CN109949889B (en) | 2019-03-29 | 2019-03-29 | Electronic medical record nursing system |
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