CN111951913A - Medical record document quality control method and system based on electronic medical record management system - Google Patents
Medical record document quality control method and system based on electronic medical record management system Download PDFInfo
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Abstract
The invention discloses a quality control method and a system of medical record documents based on an electronic medical record management system, wherein the method defines the quality control rule of the medical record documents according to a general medical record template; the electronic medical record management system pushes the electronic medical record data signed by the quality control physician; analyzing and checking a quality control object corresponding to the electronic medical record data, and giving a corresponding deduction item list; setting a quality control management list, performing quality control review and statistics, and giving a quality control value; and generating a corresponding chart and/or report page of the quality control review, and displaying the quality condition of the medical record document. The system comprises an electronic medical record management system, a medical record quality control rule configuration module, an electronic medical record data pushing module, an analysis and verification module, a medical record quality control module and a medical record quality control result overview module; and each module performs a corresponding function of the method. The method and the system automatically analyze the electronic medical records aiming at different electronic medical record management systems, reduce repeated workload and give the quality status of medical record documents on line.
Description
Technical Field
The invention relates to the technical field of informatization of medical systems, in particular to a medical record document quality control method and system based on an electronic medical record management system.
Background
The medical records are records of medical activities such as examination, diagnosis and treatment of occurrence, development and outcome of diseases of patients by medical staff, and also are important for medical treatment, prevention, teaching, scientific research, hospital management and the like by summarizing, sorting and comprehensively analyzing acquired data and writing the medical records of the patients according to specified formats and requirements. Therefore, quality control of medical records documents is of great importance.
With the application of the electronic medical record management system, a new platform is provided for the quality control of medical record documents, so that the real-time quality control of the electronic medical records becomes possible. However, most of the traditional quality control of medical record documents depends on an electronic medical record management system, is highly coupled with the electronic medical record management system, and is basically not reusable. Meanwhile, the electronic medical records, template formats and the like in different electronic medical record management systems are different, so that the difficulty of electronic medical record analysis is increased, the repeated workload is increased, the quality control of medical record documents is difficult, and a plurality of electronic medical record management systems do not provide a quality control function.
Disclosure of Invention
The technical problem to be solved by the invention is to provide a method and a system for controlling the quality of medical record documents based on an electronic medical record management system, the method and the system overcome the defect of the traditional quality control of the medical record documents, can automatically analyze the electronic medical record aiming at different electronic medical record management systems, reduce the repeated workload and provide the quality condition of the medical record documents on line.
In order to solve the technical problem, the medical record document quality control method based on the electronic medical record management system comprises the following steps:
step one, distinguishing a whole hospital, departments and a use stage according to a general medical record template of the whole hospital, defining a quality control rule of a medical record document, wherein the quality control rule is set according to a hierarchical relation, a quality control point and a deduction item of the electronic medical record structure configuration and is suitable for the requirement of the quality control rule of a place where a hospital is located;
step two, setting a Restful POST interface in the electronic medical record management system, and pushing electronic medical record data through the Restful POST interface after the electronic medical record is signed by a quality control physician;
analyzing a quality control object corresponding to the electronic medical record data through an analysis service, verifying according to a set quality control rule, and giving a corresponding deduction item list according to the quality control object;
setting a quality control management list according to a quality control rule, performing quality control review and statistics on quality control objects, and giving a quality control score according to a quality control review result;
and step five, generating a corresponding chart and/or report page of the quality control review, and clearly displaying the quality condition of the medical records and documents of the whole hospital and/or department.
Further, the quality control rule comprises a quality control range, an application stage, a quality control type and a deduction rule; wherein, the quality control range covers the whole hospital, all departments and/or part of departments, the applicable stage comprises link quality control and/or terminal quality control, and the quality control type comprises integrity, timeliness and/or consistency.
Further, the pushed electronic medical record data is in an XML format.
Further, the electronic medical record data is verified according to the set quality control rule, and the verification comprises first medical record timeliness verification and medical record characteristic missing integrity verification.
Further, the quality control evaluation comprises three-level quality control evaluation, link quality control evaluation, final quality control evaluation and/or sampling quality control evaluation; the three-level quality control evaluation comprises expert evaluation, institution evaluation and department evaluation.
The medical record document quality control system according to the control method comprises an electronic medical record management system, a medical record quality control rule configuration module, an electronic medical record data pushing module, an analysis and verification module, a medical record quality control module and a medical record quality control result overview module;
the medical record quality control rule configuration module distinguishes the whole hospital, departments and use stages according to a general medical record template of the whole hospital, defines the quality control rule of the medical record document, configures hierarchical relation, quality control points and deduction items according to the structure of the electronic medical record, and is suitable for the quality control rule requirement of the location of the hospital;
the electronic medical record data pushing module is in communication connection with the electronic medical record management system, and receives electronic medical record data signed by a quality control doctor by arranging a Restful POST interface in the electronic medical record management system;
the analysis and verification module analyzes a quality control object corresponding to the electronic medical record data according to the quality control rule defined by the medical record quality control rule configuration module, verifies the quality control object according to the set quality control rule and provides a corresponding deduction item list according to the quality control object;
the medical record quality control module sets a quality control management list according to quality control rules defined by the medical record quality control rule configuration module, performs quality control evaluation and statistics on quality control objects, and gives quality control values according to quality control evaluation results;
and the medical record quality control result overview module generates a corresponding chart and/or a report page of quality control review according to the quality control review result of the medical record quality control module, and clearly displays the medical record document quality condition of the whole hospital and/or department.
Because the medical record document quality control method and the medical record document quality control system based on the electronic medical record management system adopt the technical scheme, namely the method distinguishes the whole hospital, departments and use stages according to the general medical record template, defines the quality control rule of the medical record document, and configures the hierarchical relationship, the quality control points and the deduction items of the electronic medical record; setting a Restful POST interface in an electronic medical record management system to push electronic medical record data signed by a quality control physician; analyzing and checking a quality control object corresponding to the electronic medical record data, and giving a corresponding deduction item list; setting a quality control management list, performing quality control review and statistics, and giving a quality control value; and generating a corresponding chart and/or report page of the quality control review, and displaying the quality condition of the medical record document. The system comprises an electronic medical record management system, a medical record quality control rule configuration module, an electronic medical record data pushing module, an analysis and verification module, a medical record quality control module and a medical record quality control result overview module; and each module performs a corresponding function of the method. The method and the system overcome the defect of the quality control of the traditional medical record document, can automatically analyze the electronic medical record aiming at different electronic medical record management systems, reduce the repeated workload and give the quality condition of the medical record document on line.
Drawings
The invention is described in further detail below with reference to the following figures and embodiments:
FIG. 1 is a flow chart of a medical record document quality control method based on an electronic medical record management system according to the present invention;
fig. 2 is a schematic block diagram of a medical record document quality control system based on an electronic medical record management system according to the present invention.
Detailed Description
The embodiment is shown in fig. 1, and the medical record document quality control method based on the electronic medical record management system comprises the following steps:
step one, distinguishing a whole hospital, departments and a use stage according to a general medical record template of the whole hospital, defining a quality control rule of a medical record document, wherein the quality control rule is set according to a hierarchical relation, a quality control point and a deduction item of the electronic medical record structure configuration and is suitable for the requirement of the quality control rule of a place where a hospital is located;
step two, setting a Restful POST interface in the electronic medical record management system, and pushing electronic medical record data through the Restful POST interface after the electronic medical record is signed by a quality control physician;
analyzing a quality control object corresponding to the electronic medical record data through an analysis service, verifying according to a set quality control rule, and giving a corresponding deduction item list according to the quality control object;
setting a quality control management list according to a quality control rule, performing quality control review and statistics on quality control objects, and giving a quality control score according to a quality control review result;
and step five, generating a corresponding chart and/or report page of the quality control review, and clearly displaying the quality condition of the medical records and documents of the whole hospital and/or department.
Preferably, the quality control rule comprises a quality control range, an application stage, a quality control type and a deduction rule; wherein, the quality control range covers the whole hospital, all departments and/or part of departments, the applicable stage comprises link quality control and/or terminal quality control, and the quality control type comprises integrity, timeliness and/or consistency.
Preferably, the pushed electronic medical record data is in an XML format.
Preferably, the electronic medical record data is verified according to a set quality control rule, and the verification comprises first medical record timeliness verification and medical record characteristic missing integrity verification.
Preferably, the quality control evaluation comprises three-level quality control evaluation, link quality control evaluation, final quality control evaluation and/or sampling quality control evaluation; the three-level quality control evaluation comprises expert evaluation, institution evaluation and department evaluation.
As shown in fig. 2, the medical record document quality control system according to the control method includes an electronic medical record management system, a medical record quality control rule configuration module, an electronic medical record data push module, an analysis and verification module, a medical record quality control module, and a medical record quality control result overview module;
the medical record quality control rule configuration module distinguishes the whole hospital, departments and use stages according to a general medical record template of the whole hospital, defines the quality control rule of the medical record document, configures hierarchical relation, quality control points and deduction items according to the structure of the electronic medical record, and is suitable for the quality control rule requirement of the location of the hospital;
the electronic medical record data pushing module is in communication connection with the electronic medical record management system, and receives electronic medical record data signed by a quality control doctor by arranging a Restful POST interface in the electronic medical record management system;
the analysis and verification module analyzes a quality control object corresponding to the electronic medical record data according to the quality control rule defined by the medical record quality control rule configuration module, verifies the quality control object according to the set quality control rule and provides a corresponding deduction item list according to the quality control object;
the medical record quality control module sets a quality control management list according to quality control rules defined by the medical record quality control rule configuration module, performs quality control evaluation and statistics on quality control objects, and gives quality control values according to quality control evaluation results;
and the medical record quality control result overview module generates a corresponding chart and/or a report page of quality control review according to the quality control review result of the medical record quality control module, and clearly displays the medical record document quality condition of the whole hospital and/or department.
The method and the system are compatible with different electronic medical record management systems in a mode similar to a message middleware, are used for decoupling the electronic medical record and a quality control system, automatically analyze the electronic medical record, reduce the repeated working cost and provide the quality condition of the medical record document on line in real time.
Claims (6)
1. A medical record document quality control method based on an electronic medical record management system is characterized by comprising the following steps:
step one, distinguishing a whole hospital, departments and a use stage according to a general medical record template of the whole hospital, defining a quality control rule of a medical record document, wherein the quality control rule is set according to a hierarchical relation, a quality control point and a deduction item of the electronic medical record structure configuration and is suitable for the requirement of the quality control rule of a place where a hospital is located;
step two, setting a Restful POST interface in the electronic medical record management system, and pushing electronic medical record data through the Restful POST interface after the electronic medical record is signed by a quality control physician;
analyzing a quality control object corresponding to the electronic medical record data through an analysis service, verifying according to a set quality control rule, and giving a corresponding deduction item list according to the quality control object;
setting a quality control management list according to a quality control rule, performing quality control review and statistics on quality control objects, and giving a quality control score according to a quality control review result;
and step five, generating a corresponding chart and/or report page of the quality control review, and clearly displaying the quality condition of the medical records and documents of the whole hospital and/or department.
2. The medical record document quality control method based on the electronic medical record management system according to claim 1, characterized in that: the quality control rule comprises a quality control range, an application stage, a quality control type and a deduction rule; wherein, the quality control range covers the whole hospital, all departments and/or part of departments, the applicable stage comprises link quality control and/or terminal quality control, and the quality control type comprises integrity, timeliness and/or consistency.
3. The medical record document quality control method based on the electronic medical record management system according to claim 1, characterized in that: the pushed electronic medical record data is in an XML format.
4. The medical record document quality control method based on the electronic medical record management system according to claim 1, characterized in that: the electronic medical record data is verified according to the set quality control rule, and the verification comprises first time course recording timeliness verification and medical record characteristic missing integrity verification.
5. The medical record document quality control method based on the electronic medical record management system according to claim 1, characterized in that: the quality control evaluation comprises three-level quality control evaluation, link quality control evaluation, final quality control evaluation and/or sampling quality control evaluation; the three-level quality control evaluation comprises expert evaluation, institution evaluation and department evaluation.
6. A medical record document quality control system according to the control method of any one of claims 1 to 5, comprising an electronic medical record management system, characterized in that: the medical record quality control system also comprises a medical record quality control rule configuration module, an electronic medical record data pushing module, an analysis and verification module, a medical record quality control module and a medical record quality control result overview module;
the medical record quality control rule configuration module distinguishes the whole hospital, departments and use stages according to a general medical record template of the whole hospital, defines the quality control rule of the medical record document, configures hierarchical relation, quality control points and deduction items according to the structure of the electronic medical record, and is suitable for the quality control rule requirement of the location of the hospital;
the electronic medical record data pushing module is in communication connection with the electronic medical record management system, and receives electronic medical record data signed by a quality control doctor by arranging a Restful POST interface in the electronic medical record management system;
the analysis and verification module analyzes a quality control object corresponding to the electronic medical record data according to the quality control rule defined by the medical record quality control rule configuration module, verifies the quality control object according to the set quality control rule and provides a corresponding deduction item list according to the quality control object;
the medical record quality control module sets a quality control management list according to quality control rules defined by the medical record quality control rule configuration module, performs quality control evaluation and statistics on quality control objects, and gives quality control values according to quality control evaluation results;
and the medical record quality control result overview module generates a corresponding chart and/or a report page of quality control review according to the quality control review result of the medical record quality control module, and clearly displays the medical record document quality condition of the whole hospital and/or department.
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| CN112582044A (en) * | 2020-12-16 | 2021-03-30 | 东软集团股份有限公司 | Method and device for processing medical record, storage medium and electronic equipment |
| CN113035308A (en) * | 2021-04-19 | 2021-06-25 | 上海智赢健康科技有限公司 | Quality evaluation method and system for electronic health record |
| CN113869023A (en) * | 2021-09-27 | 2021-12-31 | 北京金山云网络技术有限公司 | Quality control data processing method and device and storage medium |
| CN116013453A (en) * | 2023-03-28 | 2023-04-25 | 中国人民解放军总医院 | Medical record writing improvement system based on artificial intelligence technology |
| CN116072254A (en) * | 2023-03-24 | 2023-05-05 | 中国人民解放军总医院 | Medical record quality analysis method and system based on machine learning |
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