CN110619935A - Method for generating clinical information registration form - Google Patents
Method for generating clinical information registration form Download PDFInfo
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- CN110619935A CN110619935A CN201910750628.6A CN201910750628A CN110619935A CN 110619935 A CN110619935 A CN 110619935A CN 201910750628 A CN201910750628 A CN 201910750628A CN 110619935 A CN110619935 A CN 110619935A
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- 238000000034 method Methods 0.000 title claims abstract description 35
- 238000012790 confirmation Methods 0.000 claims abstract description 21
- 201000010099 disease Diseases 0.000 claims description 26
- 208000037265 diseases, disorders, signs and symptoms Diseases 0.000 claims description 26
- 239000012472 biological sample Substances 0.000 claims description 6
- 238000012545 processing Methods 0.000 claims description 6
- 238000003745 diagnosis Methods 0.000 claims description 5
- 238000013523 data management Methods 0.000 description 5
- 238000007726 management method Methods 0.000 description 3
- 238000013459 approach Methods 0.000 description 2
- 230000001502 supplementing effect Effects 0.000 description 2
- 238000013461 design Methods 0.000 description 1
- 238000011161 development Methods 0.000 description 1
- 238000005516 engineering process Methods 0.000 description 1
- 238000011835 investigation Methods 0.000 description 1
- 238000012986 modification Methods 0.000 description 1
- 230000004048 modification Effects 0.000 description 1
- 238000004393 prognosis Methods 0.000 description 1
- 239000000523 sample Substances 0.000 description 1
- 238000006467 substitution reaction Methods 0.000 description 1
- 239000013589 supplement Substances 0.000 description 1
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- G—PHYSICS
- G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
- 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
- G16H10/60—ICT specially adapted for the handling or processing of patient-related medical or healthcare data for patient-specific data, e.g. for electronic patient records
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- General Health & Medical Sciences (AREA)
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- Medical Treatment And Welfare Office Work (AREA)
Abstract
The embodiment of the invention relates to a method for generating a clinical information registration form, which comprises the following steps: the server receives a clinical information registration form generation request input by a user, and generates an informed consent and consent confirmation information according to the clinical information registration form generation request; when the feedback information of the consent confirmation information is the first feedback information, generating filling instruction prompt information and a patient ID; receiving feedback information which is input by a patient and used for generating filling instruction prompt information, and acquiring size data of a current form page according to the feedback information used for generating the filling instruction prompt information; generating and outputting a clinical information registration form according to the size data of the current form page; receiving patient information input by a user and/or a patient according to the table entry and the sub-table entry information; and updating the clinical information registration table according to the patient information to obtain the clinical information registration table of the patient, and storing the clinical information registration table of the patient into the clinical information registration library.
Description
Technical Field
The invention relates to the field of data processing, in particular to a method for generating a clinical information registration table.
Background
In the information age, scientific data is called strategic resources. With the development of science, medical technology is also changing day by day. How to automatically and accurately acquire the related information becomes a problem to be solved in the technical field.
Disclosure of Invention
The invention aims to provide a method for generating a clinical information registration form, which can be used for collecting related information in a large-scale structurization mode, quickly and effectively forming a targeted information form, establishing a targeted information database and providing ordered, standardized and shared information management for the related information.
To achieve the above object, the present invention provides a method for generating a clinical information registry, the method comprising:
the method comprises the steps that a server receives a clinical information registration form generation request input by a user, and generates an informed consent and consent confirmation information according to the clinical information registration form generation request;
receiving feedback information of the consent confirmation information input by the patient;
when the feedback information of the consent confirmation information is first feedback information, generating filling instruction prompt information and a patient ID;
receiving feedback information which is input by a patient and used for generating filling description prompt information, and acquiring size data of a current form page according to the feedback information used for generating the filling description prompt information;
generating and outputting a clinical information registration form according to the size data of the current form page; the clinical information registry comprises the table entry and the sub-table entry information;
receiving patient information input by the user and/or the patient according to the table item and the sub-table item information;
and updating the clinical information registration table according to the patient information to obtain a clinical information registration table of the patient, and storing the clinical information registration table of the patient into a clinical information registration library so that the user can call the clinical information registration table of the patient from the clinical information registration library.
Preferably, the informed consent form includes usage information, descriptive information, risk information, cost information, confidential information, and contact information of a clinical information registry.
Preferably, before the generating of the filling instruction prompt message and the patient ID, the method further includes:
an item number and a clinic number corresponding to the clinical information registry generation request are acquired, and a serial number is generated such that the patient ID is composed of the item number, the clinic number, and the serial number.
Preferably, after receiving the feedback information input by the patient to generate the instruction prompt information, the method further comprises:
determining form information corresponding to the generation request of the clinical information registration form in a form list; the form information comprises the table entry and sub-table entry information corresponding to the table entry.
Further preferably, the generating of the clinical information registration form according to the size data of the current form page specifically includes:
and generating and outputting the clinical information registration table according to the size data of the current table page, the table entry and the sub-table entry information.
Further preferred is:
entries in the form information corresponding to the request for generation of the clinical information registry include: a patient basic information table entry, a registered doctor information table entry, a patient present medical history information table entry, a patient past medical history information table entry, a patient living condition information table entry, a patient eye examination information table entry, a patient preliminary diagnosis information table entry, a patient disease processing information table entry, a patient eye auxiliary examination information table entry, a patient whole body auxiliary examination information table entry and a patient biological sample information table entry.
Further preferably, after generating and outputting the clinical information registry, the method further comprises:
receiving patient basic information corresponding to the patient basic information item, and generating a disease association request according to the patient basic information;
inquiring whether patient information corresponding to the basic patient information exists in a disease database according to the disease association request;
and when the patient visit information corresponding to the basic patient information exists in the disease database, updating the past patient history information entry of the patient in the clinical information registration table and the sub-entry corresponding to the past patient history information entry of the patient according to the patient visit information.
Preferably, after the updating the clinical information registry according to the patient information, the method further comprises:
recording an update time of the clinical information registry, generating the form ID according to the update time so that the clinical information registry of the patient includes the form ID;
and generating a corresponding relation between the patient ID and the form ID, storing the corresponding relation between the patient ID and the form ID into the clinical information registry, and calling a clinical information registry of the patient by the user according to the corresponding relation between the patient ID and the form ID.
The embodiment of the invention provides a generation method of a clinical information registration form, which can be used for collecting relevant information in a large-scale structurization mode, quickly and effectively forming a targeted information form, establishing a targeted information database and providing ordered, standardized and shared information management for the relevant information.
Drawings
Fig. 1 is a flowchart of a method for generating a clinical information registry according to an embodiment of the present invention.
Detailed Description
The technical solution of the present invention is further described in detail by the accompanying drawings and embodiments.
The method for generating a clinical information registry provided in the embodiments of the present invention is implemented in a server of a clinical data management system, and is used for large-scale structured collection of medical records, medical investigation, prognosis follow-up, and sample collection, fig. 1 is a flowchart of the method for generating a clinical information registry of the present invention, and as shown in fig. 1, the method specifically includes the following steps:
step 110, the server receives a clinical information registry generation request input by a user and generates an informed consent and consent confirmation information;
in particular, a user may be understood as a medical staff member in a hospital or a person using a clinical data management system. When a user needs to collect medical records of a patient, a clinical information registry generation request needs to be input into a clinical data management system server (hereinafter referred to as a server) so that the clinical data management system can collect the medical records of the patient through collecting the clinical information registry of the patient.
And after receiving a clinical information registration form generation request input by the user, the server generates an informed consent form and consent form confirmation information according to the clinical information registration form generation request and outputs the consent form and the consent form confirmation information. An informed consent form may be understood as some relevant content that the patient should be informed about prior to establishing the clinical information registry for the clinical information registry. And after the server acquires the size data of the current form page, the server realizes the content included in the informed consent according to the size data of the current form page. At the same time or after the display of the informed consent, the server also displays consent confirmation information, which may be understood as a statement that the patient consents to the content of the informed consent.
In some specific examples, the informed consent form includes: usage information, descriptive information, risk information, cost information, confidential information, and contact information for the clinical information registry. The consent confirmation information includes the patient signature, legal guardian signature, doctor signature, signature date, and patient contact phone.
Step 120, receiving feedback information of the consent confirmation information input by the patient;
specifically, the patient inputs feedback information of the consent-confirmation information based on the content included in the informed consent form. The feedback information of the consent-confirmation information includes: first feedback information representing that the patient agrees to establish the clinical information registry after knowing the informed consent, and second feedback information representing that the patient refuses to establish the clinical information registry after knowing the informed consent.
In a specific example, when the feedback information of the agreement confirmation information is the first feedback information, the feedback information of the agreement confirmation information includes: patient signature, legal guardian signature, doctor signature, signature date, and patient contact phone fill-in information.
Step 130, when the feedback information of the agreement confirmation information is the first feedback information, generating filling instruction prompt information and a patient ID;
specifically, when the feedback information of the consent-confirmation information is the first feedback information, the server generates the filling instruction prompt information and the patient ID, indicating that the patient agrees to establish the clinical information registration form after knowing the informed consent. The information to be noticed by the user in the clinical information registry may be written in the filling instruction prompt message, for example, "in the clinical information registry, if the item is 'not done', then 'ND', if 'unknown', then 'UK', and if 'not applicable', then 'NA'. The patient ID may be understood as a unique identification code of the current patient in the clinical data management system.
In some preferred embodiments, the clinical information registry generation request includes an item number and a clinic number for identifying the item and the clinic to which the clinical information registry to be generated corresponds. When the feedback information of the consent-confirmation information is the first feedback information, the server acquires the item number and the office number corresponding to the clinical information registry generation request, and automatically generates the serial number according to the current time or the serial number, so that the patient ID is constituted by the item number, the office number, and the serial number.
Step 140, determining form information corresponding to the generation request of the clinical information registration form in the form list;
specifically, a form list is stored in the server, and form information in the clinical information registration table is stored in the form list. The form information includes the table entry and the sub-table entry information corresponding to the table entry. The server determines form information corresponding to a request for generation of a clinical information registry in the form list based on the usage information of the biological sample collection request. When the usage information of the biological sample collection request is empty, the server acquires form information of a default clinical information registry in the form list. The form information includes table entries and sub-table entries corresponding to the table entries.
In one specific example, the entries in the form information corresponding to the request for generation of the clinical information registry include: a patient basic information table entry, a registered doctor information table entry, a patient present medical history information table entry, a patient past medical history information table entry, a patient living condition information table entry, a patient eye examination information table entry, a patient preliminary diagnosis information table entry, a patient disease processing information table entry, a patient eye auxiliary examination information table entry, a patient whole body auxiliary examination information table entry and a patient biological sample information table entry.
Step 150, generating and outputting a clinical information registration table according to the size data, the table entries and the sub-table entry information of the current table page;
specifically, the current form page may be a page for printing, or a page for displaying on a computer or other display device may also be used, where different pages have different page sizes, and the server needs to obtain size data of the current form page for convenience of printing or output display. Because each different table entry and sub-table entry needs various word space and line space with different sizes when being displayed, different table entries and sub-table entries need to be arranged on the display page for the size data of different table pages, that is, a clinical information registration table is generated and output according to the size data of the current table page and the table entry and sub-table entry information in the form information. At this time, the clinical information registry may be understood as a form that is not filled in.
In a specific example, the server generates and outputs specific arrangement in the clinical information registry according to the size data, the table entry and the sub-table entry information of the current table page as shown in table 1 below.
Patient ID/patient number:
TABLE 1
Step 160, obtaining patient information;
specifically, the clinical information registry includes entry and sub-entry information. After the server generates and outputs the clinical information registry, the server obtains individual patient information corresponding to individual entry and sub-entry information in the clinical information registry.
More specifically, the manner in which the server obtains the patient information may be any one of the following two manners:
in a first approach, the server directly receives patient information entered by the user and/or patient based on entry and sub-entry information in the clinical information registry. During this process, the user and/or patient is required to enter relevant patient information that is all of the table entry and sub-table entry information in the clinical information registry. It will be appreciated that entries and sub-entries in different clinical information registries may be entered by different people than the entries and sub-entries. For example, the entry of the registered doctor information in the entry is entered by the medical staff, i.e., the user, while the other contents of the entry may be entered by both the medical staff and the patient.
In the second mode, the server first only needs to receive the patient basic information corresponding to the patient basic information items in the clinical information registry. Then, the server generates a disease association request according to the patient basic information, and inquires whether patient information corresponding to the patient basic information exists in a disease database according to the disease association request. A disease database is understood to be a database for storing various disease information and treatment records of patients.
When patient visit information corresponding to the patient basic information exists in the disease database, the server generates patient information corresponding to other entries and sub-entries in the clinical information registry according to the patient visit information. That is, in this process, the user or patient only needs to input the patient basic information corresponding to the patient basic information item in the clinical information registry, and the patient information corresponding to the other entries and sub-entries in the clinical information registry is obtained by the server-associated disease database.
When patient information corresponding to the basic information of the patient exists in the disease database, but the patient information generated by the server according to the patient information does not meet the necessary filling table entry and/or the sub-table entry in the clinical information registration table, the server generates prompt information for supplementing filling information, and prompts a user or the patient that the patient information corresponding to the necessary filling table entry and the sub-table entry in the clinical information registration table needs to be input in a supplementing mode.
When the patient information corresponding to the basic information of the patient does not exist in the disease database, the server generates prompt information for continuous filling, and prompts the user or the patient to continuously input the patient information corresponding to other entries and sub-entries in the clinical information registry.
In a specific example, the server receives the basic information of the patient as "wangzhi, man, 50 years old, identification number xxx". The table entries that must be filled in the clinical registry include: patient basic information entries, registered doctor information entries, patient present medical history information entries, patient past medical history information entries, patient eye examination information entries, patient preliminary diagnosis information entries, and patient disease processing information entries, where entries that are not necessarily filled include: a patient life condition information table item, a patient eye auxiliary examination information table item, a patient whole body auxiliary examination information table item and a patient biological sample information table item.
The server generates a disease association request according to the basic information of the patient, and inquires and acquires a plurality of pieces of patient information corresponding to the past medical history information table item and the sub-table item of the patient of which the basic information of the patient is 'Wangzhi, Man, 50 years old and ID number xxx' in a disease database according to the disease association request. And because the registered doctor information table entry, the patient current medical history information table entry, the patient previous medical history information table entry, the patient eye examination information table entry, the patient preliminary diagnosis information table entry and the patient disease processing information table entry in the table entries are all necessary filling entries, the server generates prompt information of supplementary information of 'please continue to fill in relevant necessary filling contents' for the user or the patient to supplement the patient information in the table entries which are not filled and relevant sub-entries thereof according to the prompt information of the supplementary information.
It is understood that both of the above ways may be that the server obtains the patient information. In the first approach, the server may obtain comprehensive patient information at once, but more information needs to be entered by the patient and/or the user. In the second mode, the server obtains the patient information corresponding to all or part of the entries through the associated disease database according to the basic information of the patient, so that the load of inputting a large amount of information by the user and/or the patient can be reduced although the operation pressure of the server is increased compared with the first mode. The user can combine the advantages and disadvantages of the two modes to set the server to acquire the patient information in which mode according to the needs.
Step 170, updating the clinical information registration table according to the patient information to obtain the clinical information registration table of the patient;
specifically, after the server acquires the patient information, the server updates the clinical information registration table according to the patient information to acquire the clinical information registration table of the patient. At this time, the clinical information registry of the patient may be understood as a clinical information registry that has been filled in. The clinical information registry of the patient includes a patient ID. The patient ID may be a unique identifier used to identify patient identification information, such as a patient identification number or a mobile phone number.
Step 180, storing the clinical information registry of the patient into a clinical information registry;
specifically, the server stores the clinical information registry of the patient into the clinical information registry for the user to call the clinical information registry of the patient from the clinical information registry.
In some preferred embodiments, prior to storing the clinical information registry of the patient to the clinical information registry, the server records an update time of the clinical information registry and generates the form ID based on the update time such that the clinical information registry of the patient includes the form ID. Then, the corresponding relation between the patient ID and the form ID is generated, and the corresponding relation between the patient ID and the form ID is stored in a clinical information registry so that a user can call a clinical information registry of the patient according to the corresponding relation between the patient ID and the form ID. After the corresponding relation between the patient ID and the form ID is generated, the clinical information registration table of the patient corresponding to the patient ID can be maintained according to the patient ID, so that the clinical information registration table of the patient is more convenient to maintain and call.
The generation method of the clinical information registration form can be used for large-scale structured collection of relevant information, quickly and effectively forming the targeted information form, establishing the targeted information database and providing ordered, standardized and shared information management for the relevant information.
Those of skill would further appreciate that the various illustrative components and algorithm steps described in connection with the embodiments disclosed herein may be implemented as electronic hardware, computer software, or combinations of both, and that the various illustrative components and steps have been described above generally in terms of their functionality in order to clearly illustrate this interchangeability of hardware and software. Whether such functionality is implemented as hardware or software depends upon the particular application and design constraints imposed on the implementation. Skilled artisans may implement the described functionality in varying ways for each particular application, but such implementation decisions should not be interpreted as causing a departure from the scope of the present invention.
The steps of a method or algorithm described in connection with the embodiments disclosed herein may be embodied in hardware, a software module executed by a processor, or a combination of the two. A software module may reside in Random Access Memory (RAM), memory, Read Only Memory (ROM), electrically programmable ROM, electrically erasable programmable ROM, registers, hard disk, a removable disk, a CD-ROM, or any other form of storage medium known in the art.
The above-mentioned embodiments are intended to illustrate the objects, technical solutions and advantages of the present invention in further detail, and it should be understood that the above-mentioned embodiments are merely exemplary embodiments of the present invention, and are not intended to limit the scope of the present invention, and any modifications, equivalent substitutions, improvements and the like made within the spirit and principle of the present invention should be included in the scope of the present invention.
Claims (8)
1. A method of generating a clinical information registry, the method comprising:
the method comprises the steps that a server receives a clinical information registration form generation request input by a user, and generates an informed consent and consent confirmation information according to the clinical information registration form generation request;
receiving feedback information of the consent confirmation information input by the patient;
when the feedback information of the consent confirmation information is first feedback information, generating filling instruction prompt information and a patient ID;
receiving feedback information which is input by a patient and used for generating filling description prompt information, and acquiring size data of a current form page according to the feedback information used for generating the filling description prompt information;
generating and outputting a clinical information registration form according to the size data of the current form page; the clinical information registry comprises the table entry and the sub-table entry information;
receiving patient information input by the user and/or the patient according to the table item and the sub-table item information;
and updating the clinical information registration table according to the patient information to obtain a clinical information registration table of the patient, and storing the clinical information registration table of the patient into a clinical information registration library so that the user can call the clinical information registration table of the patient from the clinical information registration library.
2. The method of claim 1, wherein the informed consent comprises: usage information, descriptive information, risk information, cost information, confidential information, and contact information for the clinical information registry.
3. The method of claim 1, wherein prior to said generating the filling instruction prompt message and the patient ID, the method further comprises:
an item number and a clinic number corresponding to the clinical information registry generation request are acquired, and a serial number is generated such that the patient ID is composed of the item number, the clinic number, and the serial number.
4. The method of claim 1, wherein after receiving patient input feedback information generating instructional prompt information, the method further comprises:
determining form information corresponding to the generation request of the clinical information registration form in a form list; the form information comprises the table entry and sub-table entry information corresponding to the table entry.
5. The method of claim 4, wherein generating a clinical information registry from the size data of the current form page is specifically:
and generating and outputting the clinical information registration table according to the size data of the current table page, the table entry and the sub-table entry information.
6. The method of claim 4, wherein:
entries in the form information corresponding to the request for generation of the clinical information registry include: a patient basic information table entry, a registered doctor information table entry, a patient present medical history information table entry, a patient past medical history information table entry, a patient living condition information table entry, a patient eye examination information table entry, a patient preliminary diagnosis information table entry, a patient disease processing information table entry, a patient eye auxiliary examination information table entry, a patient whole body auxiliary examination information table entry and a patient biological sample information table entry.
7. The method of claim 6, wherein after generating and outputting the clinical information registry, the method further comprises:
receiving patient basic information corresponding to the patient basic information item, and generating a disease association request according to the patient basic information;
inquiring whether patient information corresponding to the basic patient information exists in a disease database according to the disease association request;
and when the patient visit information corresponding to the basic patient information exists in the disease database, updating the past patient history information entry of the patient in the clinical information registration table and the sub-entry corresponding to the past patient history information entry of the patient according to the patient visit information.
8. The method of claim 1, wherein after said updating the clinical information registry according to the patient information, the method further comprises:
recording an update time of the clinical information registry, generating the form ID according to the update time so that the clinical information registry of the patient includes the form ID;
and generating a corresponding relation between the patient ID and the form ID, storing the corresponding relation between the patient ID and the form ID into the clinical information registry, and calling a clinical information registry of the patient by the user according to the corresponding relation between the patient ID and the form ID.
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| US20120004931A1 (en) * | 2010-07-02 | 2012-01-05 | Sure-Shot Medical Device, Inc. | System and Method for Form Record Processing |
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| Publication number | Priority date | Publication date | Assignee | Title |
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| US20120004931A1 (en) * | 2010-07-02 | 2012-01-05 | Sure-Shot Medical Device, Inc. | System and Method for Form Record Processing |
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