CN114360671A

CN114360671A - Electronic medical record generation method and device, storage medium and electronic device

Info

Publication number: CN114360671A
Application number: CN202011044878.7A
Authority: CN
Inventors: 彭俊钦
Original assignee: Beijing Kingsoft Cloud Network Technology Co Ltd
Current assignee: Beijing Kingsoft Cloud Network Technology Co Ltd
Priority date: 2020-09-28
Filing date: 2020-09-28
Publication date: 2022-04-15

Abstract

The application provides a method and a device for generating an electronic medical record, a storage medium and an electronic device, wherein the method comprises the following steps: displaying an electronic medical record template in a target display area of an electronic medical record editor, wherein the electronic medical record template is displayed by using a target document application integrated in the electronic medical record editor and comprises a plurality of content controls allowing information input; detecting a plurality of input operations executed on a plurality of content controls, wherein each input operation in the plurality of input operations is used for inputting one type of target object data corresponding to a target object in one content control in the plurality of content controls; and responding to the plurality of input operations to generate a target electronic medical record of the target object, wherein the target electronic medical record contains target object data corresponding to each content control in the plurality of content controls. By the method and the device, the problem that an electronic case acquisition mode in the related technology is high in labor cost due to the fact that the acquisition process is complex is solved.

Description

Electronic medical record generation method and device, storage medium and electronic device

Technical Field

The present application relates to the field of internet, and in particular, to a method and an apparatus for generating an electronic medical record, a storage medium, and an electronic apparatus.

Background

The medical record is the original record of the whole process of the diagnosis and treatment of the patient in the hospital, and generally comprises the following components: home page, history of disease, examination results, medical orders, surgical records, nursing records, and the like. Medical records can be divided into: paper medical records and electronic medical records. Electronic medical records are increasingly used by hospitals due to the characteristics of easy storage, easy carrying and the like.

Electronic Medical Record (EMR), also called computerized Medical Record system, or Computer-Based Patient Record (CPR), refers to a digitized Medical service Record, i.e., a digitized Patient Medical Record, for clinical diagnosis and treatment and guided intervention of Medical institutions for outpatients and inpatients (or health care subjects), and can replace a handwritten paper Medical Record.

Electronic medical records can manage information about the health status and healthcare behavior of an individual electronically, information relating to all the processes of collection, storage, transmission, processing and utilization of patient information. The electronic medical record not only refers to static medical record information, but also comprises provided related services, and complete and accurate diagnosis and treatment records can be provided for users (such as patients and doctors) through the electronic medical record. The electronic medical record can be stored, managed, transmitted and reproduced by electronic equipment (a computer, a health card and the like), and has the characteristics of initiative, completeness, correctness, knowledge association, timely acquisition and the like.

Due to the particularity of the format of the case, the electronic medical record is more complex in acquisition process and high in labor cost compared with a paper medical record. In the related art, a special editor is usually used to write the function of writing an electronic case in a programming language. However, the above-mentioned electronic medical record acquisition method requires a large amount of computer hardware investment and personnel training, and the effect is not ideal, and often after many times of training, doctors still cannot write medical records quickly, requiring a great time investment. Moreover, the structured data cannot be perfectly verified, the situation of data loss often occurs, and higher complexity is brought to later statistics and scientific research. In addition, the electronic medical record files depend on respective software (editors) strongly, and cannot be shared compatibly.

Therefore, the electronic case acquisition method in the related art has a problem of high labor cost due to a complicated acquisition process.

Disclosure of Invention

The application provides a method and a device for generating an electronic medical record, a storage medium and an electronic device, which are used for at least solving the problem of high labor cost caused by complex acquisition process of an electronic medical record acquisition mode in the related technology.

According to an aspect of the embodiments of the present application, there is provided a method for generating an electronic medical record, including: displaying an electronic medical record template in a target display area of an electronic medical record editor, wherein the electronic medical record template is displayed by using a target document application integrated in the electronic medical record editor, and the electronic medical record template comprises a plurality of content controls allowing information input; detecting a plurality of input operations performed on the plurality of content controls, wherein each input operation in the plurality of input operations is used for inputting one type of target object data corresponding to a target object in one content control in the plurality of content controls; and responding to the plurality of input operations, and generating a target electronic medical record of the target object, wherein the target electronic medical record contains the target object data corresponding to each content control in the plurality of content controls.

Optionally, before displaying the electronic medical record template in the target display area of the electronic medical record editor, the method further includes: displaying a template configuration area of the electronic medical record template in a template configuration interface of target equipment; adding a plurality of data elements in the template configuration area, wherein the data elements correspond to the content controls one by one, and each data element in the data elements contains a control identification of each content control corresponding to the data element and an input box of each content control; and generating the electronic medical record template containing the plurality of content controls according to the plurality of data elements, wherein the electronic medical record template only allows information input in the input box of each content control.

Optionally, displaying the electronic medical record template in the target display area of the electronic medical record editor includes: detecting a trigger operation executed on a first interface of the electronic medical record editor, wherein the trigger operation is used for triggering generation of the target electronic medical record corresponding to the target object; and responding to the triggering operation, calling the electronic medical record template, and displaying the electronic medical record template in the target display area of a second interface of the electronic medical record editor.

Optionally, after displaying the electronic medical record template in the target display area of the electronic medical record editor, the method further includes: acquiring preset object data corresponding to the target object, wherein the preset object data is one or more object data of the target object configured in advance; determining a target content control corresponding to the preset object data from the plurality of content controls; and automatically inputting the preset object data in the target content control.

Optionally, generating the target electronic medical record of the target object includes: acquiring a plurality of target object data corresponding to the plurality of content controls, wherein the plurality of content controls correspond to the plurality of target object data one to one; performing data validity check and data integrity check on a plurality of target object data; and under the condition that the data validity check and the data integrity check both pass, generating the target electronic medical record of the target object.

Optionally, after generating the target electronic medical record of the target object, the method further includes: generating target structured data corresponding to the target electronic medical record, wherein the target structured data is used for representing a corresponding relation between the control identification of each content control and the target object data corresponding to each content control; and sending the target structured data to a first server for storage.

Optionally, after generating the target electronic medical record of the target object, the method further includes: configuring target medical record data in the target electronic medical record into a locked state, wherein the target medical record data comprises the target object data corresponding to each content control, and the locked state is a state which is not allowed to be modified; and sending the target electronic medical record to a second server for storage.

According to another aspect of the embodiments of the present application, there is provided an apparatus for generating an electronic medical record, including: the electronic medical record editor comprises a first display unit, a second display unit and a display unit, wherein the first display unit is used for displaying an electronic medical record template in a target display area of the electronic medical record editor, the electronic medical record template is displayed by using a target document application integrated in the electronic medical record editor, and the electronic medical record template comprises a plurality of content controls allowing information input; a detecting unit, configured to detect a plurality of input operations performed on the plurality of content controls, where each of the plurality of input operations is used to input one type of target object data corresponding to a target object in one of the plurality of content controls; and the first generating unit is used for responding to the plurality of input operations and generating a target electronic medical record of the target object, wherein the target electronic medical record contains the target object data corresponding to each content control in the plurality of content controls.

Optionally, the apparatus further comprises: the second display unit is used for displaying the template configuration area of the electronic medical record template in a template configuration interface of target equipment before the electronic medical record template is displayed in the target display area of the electronic medical record editor; an adding unit, configured to add a plurality of data elements in the template configuration area, where the plurality of data elements correspond to the plurality of content controls one to one, and each data element in the plurality of data elements includes a control identifier of each content control corresponding to the each data element, and an input box of each content control; and a second generating unit, configured to generate the electronic medical record template including the plurality of content controls according to the plurality of data elements, where the electronic medical record template only allows information to be input in the input box of each content control.

Optionally, the first display unit includes: the detection module is used for detecting a trigger operation executed on a first interface of the electronic medical record editor, wherein the trigger operation is used for triggering generation of the target electronic medical record corresponding to the target object; and the display module is used for responding to the triggering operation, calling the electronic medical record template and displaying the electronic medical record template in the target display area of the second interface of the electronic medical record editor.

Optionally, the apparatus further comprises: an obtaining unit, configured to obtain preset object data corresponding to the target object after the electronic medical record template is displayed in the target display area of the electronic medical record editor, where the preset object data is one or more object data of the target object configured in advance; a determining unit, configured to determine, from the plurality of content controls, a target content control corresponding to the preset object data; and the input unit is used for automatically inputting the preset object data in the target content control.

Optionally, the first generating unit includes: an obtaining module, configured to obtain a plurality of target object data corresponding to the plurality of content controls, where the plurality of content controls correspond to the plurality of target object data one to one; the verification module is used for performing data validity verification and data integrity verification on the target object data; and the generating module is used for generating the target electronic medical record of the target object under the condition that the data validity check and the data integrity check are passed.

Optionally, the apparatus further comprises: a third generating unit, configured to generate target structured data corresponding to the target electronic medical record after generating the target electronic medical record of the target object, where the target structured data is used to represent a correspondence between a control identifier of each content control and the target object data corresponding to each content control; and the first sending unit is used for sending the target structured data to the first server for storage.

Optionally, the apparatus further comprises: a configuration unit, configured to configure target medical record data in the target electronic medical record into a locked state after the target electronic medical record of the target object is generated, where the target medical record data includes the target object data corresponding to each content control, and the locked state is a state in which modification is not allowed; and the second sending unit is used for sending the target electronic medical record to a second server for storage.

According to a further aspect of an embodiment of the present application, there is also provided a computer-readable storage medium having a computer program stored thereon, wherein the computer program is configured to perform the steps of any of the above method embodiments when executed.

According to a further aspect of an embodiment of the present application, there is also provided an electronic apparatus, including a memory and a processor, the memory storing a computer program therein, the processor being configured to execute the computer program to perform the steps in any of the above method embodiments.

In the embodiment of the application, a mode of integrating document application in an electronic medical record editor is adopted, and an electronic medical record template is displayed in a target display area of the electronic medical record editor, wherein the electronic medical record template is a template displayed by using the target document application integrated in the electronic medical record editor, and comprises a plurality of content controls allowing information input; detecting a plurality of input operations executed on a plurality of content controls, wherein each input operation in the plurality of input operations is used for inputting one type of target object data corresponding to a target object in one content control in the plurality of content controls; the method comprises the steps of responding to a plurality of input operations, generating a target electronic medical record of a target object, wherein the target electronic medical record comprises target object data corresponding to each content control in a plurality of content controls, integrating document application (document application with the content controls) into an electronic medical record editor, and generating the electronic medical record only by inputting object data (such as patient information and diagnosis and treatment information) into the content controls by a user (such as a doctor).

Drawings

The accompanying drawings, which are incorporated in and constitute a part of this specification, illustrate embodiments consistent with the invention and together with the description, serve to explain the principles of the invention.

In order to more clearly illustrate the embodiments of the present invention or the technical solutions in the prior art, the drawings used in the description of the embodiments or the prior art will be briefly described below, and it is obvious for those skilled in the art that other drawings can be obtained according to the drawings without inventive exercise.

FIG. 1 is a diagram illustrating a hardware environment of an alternative method for generating an electronic medical record according to an embodiment of the present invention;

fig. 2 is a schematic flow chart diagram illustrating an alternative method for generating an electronic medical record according to an embodiment of the present application;

FIG. 3 is a diagram of an alternative electronic medical record template according to an embodiment of the present application;

FIG. 4 is a schematic diagram of an optional add data element according to an embodiment of the present application;

FIG. 5 is a schematic diagram of an alternative electronic medical record generation interface according to an embodiment of the application;

FIG. 6 is a schematic diagram of an alternative electronic medical record generation interface according to an embodiment of the application;

FIG. 7 is a schematic diagram of an alternative XML structured information according to an embodiment of the present application;

FIG. 8 is a schematic flow chart diagram illustrating an alternative method for generating an electronic medical record according to an embodiment of the present application;

fig. 9 is a flowchart illustrating a method for generating an alternative electronic medical record according to an embodiment of the present application;

FIG. 10 is a schematic diagram of an alternative apparatus for generating an electronic medical record according to an embodiment of the present application;

fig. 11 is a block diagram of an alternative electronic device according to an embodiment of the present application.

Detailed Description

In order to make the technical solutions better understood by those skilled in the art, the technical solutions in the embodiments of the present application will be clearly and completely described below with reference to the drawings in the embodiments of the present application, and it is obvious that the described embodiments are only partial embodiments of the present application, but not all embodiments. All other embodiments, which can be derived by a person skilled in the art from the embodiments given herein without making any creative effort, shall fall within the protection scope of the present application.

It should be noted that the terms "first," "second," and the like in the description and claims of this application and in the drawings described above are used for distinguishing between similar elements and not necessarily for describing a particular sequential or chronological order. It is to be understood that the data so used is interchangeable under appropriate circumstances such that the embodiments of the application described herein are capable of operation in sequences other than those illustrated or described herein. Furthermore, the terms "comprises," "comprising," and "having," and any variations thereof, are intended to cover a non-exclusive inclusion, such that a process, method, system, article, or apparatus that comprises a list of steps or elements is not necessarily limited to those steps or elements expressly listed, but may include other steps or elements not expressly listed or inherent to such process, method, article, or apparatus.

First, partial nouns or terms appearing in the description of the embodiments of the present application are applicable to the following explanations:

data element: a data element defining, identifying, representing and allowing values is described by a set of attributes, and the data element is composed of three parts: object, property, representation.

According to one aspect of the embodiment of the application, a method for generating an electronic medical record is provided. Alternatively, in this embodiment, the method for generating an electronic medical record may be applied to a hardware environment formed by the terminal 101 and the server 103 as shown in fig. 1. As shown in fig. 1, a server 103 is connected to a terminal 101 through a network, which may be used to provide services (such as game services, application services, etc.) for the terminal or a client installed on the terminal, and a database may be provided on the server or separately from the server for providing data storage services for the server 103, and the network includes but is not limited to: the terminal 101 is not limited to a PC, a mobile phone, a tablet computer, and the like.

Optionally, in this embodiment, the server 103 may be a server in a distributed message system, a cloud server, a server cluster, or a similar device. One or more layers of gateways may be deployed between the server 103 and the intermediary. The method for generating the electronic medical record according to the embodiment of the application may be executed by the gateway, the server 103, the terminal 101, or the gateway, the server 103 and the terminal 101. The method for generating the electronic medical record executed by the terminal 101 according to the embodiment of the present application may be executed by a client installed thereon.

Fig. 2 is a schematic flowchart of an alternative method for generating an electronic medical record according to an embodiment of the present application, and as shown in fig. 2, the method may include the following steps:

step S202, displaying an electronic medical record template in a target display area of an electronic medical record editor, wherein the electronic medical record template is displayed by using a target document application integrated in the electronic medical record editor, and the electronic medical record template comprises a plurality of content controls allowing information input;

step S204, detecting a plurality of input operations executed on a plurality of content controls, wherein each input operation in the plurality of input operations is used for inputting one target object data corresponding to a target object in one content control in the plurality of content controls;

and step S206, responding to a plurality of input operations, and generating a target electronic medical record of the target object, wherein the target electronic medical record contains target object data corresponding to each content control in the plurality of content controls.

Through the steps S202 to S206, displaying an electronic medical record template in a target display area of the electronic medical record editor, wherein the electronic medical record template is a template displayed by using a target document application integrated in the electronic medical record editor, and the electronic medical record template includes a plurality of content controls allowing information input; detecting a plurality of input operations executed on a plurality of content controls, wherein each input operation in the plurality of input operations is used for inputting one type of target object data corresponding to a target object in one content control in the plurality of content controls; the target electronic medical record of the target object is generated in response to the plurality of input operations, wherein the target electronic medical record comprises target object data corresponding to each content control in the plurality of content controls, the problem that the electronic medical record acquisition mode in the related technology is high in labor cost due to the fact that the acquisition process is complex is solved, the generation efficiency of the electronic medical record is improved, and labor cost is saved.

In the technical solution provided in step S202, an electronic medical record template is displayed in a target display area of an electronic medical record editor, where the electronic medical record template is a template displayed by using a target document application integrated in the electronic medical record editor, and the electronic medical record template includes a plurality of content controls allowing information input.

The method for generating the electronic medical record in the embodiment can be applied to a scene in which the electronic medical record needs to be generated, for example, a medical staff in a hospital generates the electronic medical record for a patient by using an electronic medical record editor. For other scenes in which a professional field is generated by using an editor, the method for generating the electronic medical record in the embodiment is also applicable.

A user (e.g., a healthcare worker) can log in an electronic medical record generation client (corresponding to an electronic medical record generation system) running on his terminal device (e.g., a desktop computer) or a client (corresponding to a target system) with electronic medical record generation functions by using an account number and a corresponding password. Taking an electronic medical record generation client as an example, the electronic medical record generation client may include an electronic medical record editor. Optionally, the electronic medical record editor may also be directly run on the terminal device, so as to generate a target electronic medical record of a target object (a certain patient) through the electronic medical record editor.

The target document application can be integrated in the electronic medical record editor or embedded in the electronic medical record editor, and the target document application can be a document application with a content control, such as Word, WPS, and the like. Content controls are single controls that can be added and customized and can be used in templates, forms, and documents.

The electronic medical record template can be a template displayed by a target document application integrated in an electronic medical record editor, and a plurality of content controls which allow information to be input can be contained in the electronic medical record template, wherein the content controls can be abstract and example content controls. The format of the electronic medical record template can be the same as the format of the document output by the target document application.

An example of an electronic medical record template can be shown in fig. 3, and descriptive information can be included in the electronic medical record template, and the descriptive information can include: the first information (e.g., electronic medical record description, etc.) for describing the electronic medical record, the second information for describing information to be entered in the content control, and the descriptive information can be entered using conventional functionality (e.g., writing, inserting, etc.) of the target document application.

Alternatively, in order to avoid visual deviation of the generated electronic medical record display, the electronic medical record document may be configured to allow only the input operation to be performed on the content control, and not to allow other operations than the input operation described above to be performed. For example, editing of information in other positions in the electronic medical record document besides the content control is not allowed, and the size, position, etc. of the content control are not allowed to be adjusted.

The electronic medical record editor can include a target display area for electronic medical record generation. The electronic medical record template can be firstly displayed in the target display area, so that medical personnel can conveniently generate the electronic medical record on the basis of the electronic medical record template.

In the technical solution provided in step S204, a plurality of input operations performed on a plurality of content controls are detected, where each of the plurality of input operations is used to input one type of target object data corresponding to a target object in one of the plurality of content controls.

For all or part of content controls in the electronic medical record template, a user can input target object data corresponding to a target object through input equipment. The input device may be a keyboard, a touch screen, a mouse, a remote controller, or the like, and may also be a device for performing voice recognition (a user inputs object data by means of voice).

The target object data corresponding to the target object may be used to describe a clinical record of the target object, and may include, but is not limited to, at least one of: diagnosis and treatment time, diagnosis and treatment address (in hospital), contact information, course of disease record, examination and examination result, medical advice, operation record, nursing record and the like. Different hospitals and different consulting rooms can use the same electronic medical record template and can also use different electronic medical record templates. This is not limited in this embodiment.

The electronic medical record editor can detect a plurality of input operations performed on a plurality of content controls, wherein each input operation is used for inputting one type of target object data corresponding to a target object in one content control in the plurality of content controls. The number of content controls and the number of multiple input operations may be the same or different, e.g., the number of input operations may be greater than the number of content controls (modified after input). The plurality of input operations may be all input by the user through the input device, or may be automatically input by the electronic editor according to the acquired information.

For example, when a doctor writes a disease, the manufactured template can be called to generate a medical document of a patient, and each content control writes a value to the content control by calling the underlying method of the WPS content control.

In the technical solution provided in step S206, a target electronic medical record of the target object is generated in response to a plurality of input operations, where the target electronic medical record includes target object data corresponding to each content control of the plurality of content controls.

Optionally, after a plurality of input operations, the user may perform a target operation on a target button in the electronic medical record editor (e.g., a click operation performed on a "OK" button) to trigger generation of a target electronic medical record for the target object.

In order to generate the target electronic medical record, the electronic medical record editor can acquire target object data corresponding to each content control, namely, target object data input by each input operation, in response to a plurality of input operations.

After the target object data corresponding to each content control is acquired, the electronic medical record editor may generate a target electronic medical record of the target object by using the acquired target object data corresponding to each content control and other data except for the content control in the electronic medical record template. The format of the target electronic medical record can be the same as the format of the document output by the target document application.

As an alternative embodiment, before displaying the electronic medical record template in the target display area of the electronic medical record editor, the method further includes:

s11, displaying a template configuration area of the electronic medical record template in a template configuration interface of the target equipment;

s12, adding a plurality of data elements in the template configuration area, wherein the data elements correspond to a plurality of content controls one by one, and each data element in the data elements comprises a control identification of each content control corresponding to each data element and an input box of each content control;

and S13, generating an electronic medical record template containing a plurality of content controls according to the plurality of data elements, wherein the electronic medical record template only allows information input in the input box of each content control.

The electronic medical record template can be generated first before being used. The target device for generating the electronic medical record template may be the same device as the device for generating the electronic medical record by using the electronic medical record editor, or may be a different device, which is not limited in this embodiment.

When the target device is used to generate the electronic medical record template, a template configuration interface can be first called in an editing mode of an electronic medical record editor or in the electronic medical record template editor (integrated with a target document application), and a template configuration area, which can be an editing area of the electronic medical record template, is displayed in the template configuration interface. In this embodiment, an electronic medical record template editor is taken as an example for description.

When the electronic medical record template is manufactured, the content control applied by the target document can be abstracted into a program controllable control, namely a data element through the code. A template can be made by performing normal functional operations (writing, inserting, etc.) on a target document application (e.g., WPS) in conjunction with inserting data elements (content controls) to generate a specialized medical document (electronic medical record template).

The template maker may add a plurality of data elements (EMR data elements) in the template configuration area, for example, by clicking a right mouse button to select an option of adding a data element from a list of retrieved options, thereby adding a new data element, or by copying and pasting an existing data element, or by clicking or dragging an icon for adding a data element in a toolbar, the display interface when a data element is added may be as shown in fig. 4.

For a data element, may include: the control identifier of the content control corresponding to the content control, and the input box of the content control, where the control identifier may include: a type code and a type name, the type of the input box may be, but is not limited to, at least one of: text boxes, drop down boxes, multi-selection lists, check boxes, and the like.

For example, the input box of the content control "occupation" is a drop-down box, and in the electronic medical record generation interface, as shown in fig. 5, by clicking the drop-down box corresponding to "occupation", a plurality of configured occupation options can be called.

The template maker can add a plurality of data elements in the template configuration interface, the data elements correspond to the content controls one by one, and each data element in the data elements contains a control identification of the content control corresponding to the data element and an input box of the content control.

The target device can generate an electronic medical record template containing a plurality of content controls according to the added plurality of data elements. The electronic medical record template can also contain information written and inserted by using the conventional functions of the target program application. In the electronic medical record template, only information input in the input box of each content control is allowed, and for other positions in the electronic medical record template, input and adjustment are not allowed.

For example, as shown in fig. 3, a content control is inserted into each place to be filled by the doctor, and the information at other positions except the content control is not allowed to be edited.

While the electronic medical record template is generated, structured data corresponding to the electronic medical record template, such as XML structured information, may also be generated, and an example of the XML structured information may be:

<Data>

< Group DataCode ═ data Group ID "ControlID ═ content control ID" UnitType ═ content control type "parantcontrolid ═ superior content control ID" parantdatacode ═ superior data Group ID "isenableditionary ═ dictionary enabled >

< FeildDataCode ═ Data element ID "control ID ═ content control ID" UnitType ═ content control type "parantcontrol ID ═ superior content control ID" parantdatacode ═ superior Data ID "isenableditionary ═ feilld > </Group > </Data >

Control ID ═ Tag ═ Control type ═ Title ═ plan holder Text ═ placeholder "lockcontrol ═ lock Control ═ lock controls ═ lock contents ═ Text ═ v >/EmrControls >

</Document>

According to the embodiment, the data elements (EMR data elements) are obtained by abstracting and instantiating the content control of the document application, and the electronic medical record template is generated by adding the data elements, so that the generation efficiency of the electronic medical record template can be improved, and related personnel (such as medical personnel) can write the electronic medical record conveniently and quickly.

As an alternative embodiment, displaying the electronic medical record template in the target display area of the electronic medical record editor includes:

s21, detecting a trigger operation executed on a first interface of the electronic medical record editor, wherein the trigger operation is used for triggering generation of a target electronic medical record corresponding to a target object;

and S22, responding to the trigger operation, calling the electronic medical record template, and displaying the electronic medical record template in a target display area of a second interface of the electronic medical record editor.

Before the electronic medical record template is displayed, a user can trigger an electronic medical record generation interface entering a target object through a trigger operation. A first interface of the electronic medical record editor can display a list of objects (a list of users), each object (a user) in the list of objects corresponding to a patient.

For a target object in the object list, the generation of an electronic medical record corresponding to the target object may be triggered by clicking or other touch operations (e.g., clicking a radio box corresponding to the target object and clicking a confirmation button), for example, entering an electronic medical record generation interface (a second interface) of the target object.

When entering the second interface, the terminal device may call the electronic medical record template, and the electronic medical record template may be stored locally in the terminal device, or may be stored in a server or a database communicatively connected to the terminal device. After the electronic medical record template is called, the terminal device can display the electronic medical record template in a target display area of a second interface of the electronic medical record editor.

Through the embodiment, the electronic medical record generation interface is triggered to enter through the triggering operation executed on the interface, and the convenience of electronic medical record generation can be improved.

As an alternative embodiment, after the electronic medical record template is displayed in the target display area of the electronic medical record editor, the method further includes:

s31, acquiring preset object data corresponding to the target object, wherein the preset object data is one or more object data of the preset target object;

s32, determining a target content control corresponding to the preset object data from the plurality of content controls;

s33, preset object data is automatically input in the target content control.

While the electronic medical record interface is displayed, the terminal equipment can acquire preset object data corresponding to the target object, wherein the preset object data is one or more object data of the preset target object. The preset object data refers to object data of a target object, which is previously configured (or acquired), and may be content unrelated to the diagnosis and treatment result of the present visit.

For example, the preset object data may include: name of medical institution, hospital admission, health card number, case number, etc. at which the target subject is to be treated. For another example, the preset object data may include: the name, sex, date of birth, age, nationality, place of birth, native place, identification number, occupation, current address, etc. of the target subject.

The terminal device may determine, from the plurality of content controls, a target content control corresponding to the preset object data, where the number of the target content controls is positively correlated with the number of the preset object data, for example, the number of the target content controls may be greater than or equal to the type of the object data, where part of the object data may correspond to the plurality of content controls (for example, where the object is born, etc.), and this is not limited in this embodiment.

The terminal equipment can automatically fill the preset object data into the corresponding target content control, so that part of content controls in the electronic medical record template can be automatically filled.

The object relationship between the preset object data and the content control can be determined according to the structured data corresponding to the electronic medical record template. For example, the EmrControls can be traversed through the XML file (XML structured information) of the template, so as to obtain the content control ControlID and the DataCode in the Field, the meaning represented by the content control is obtained through the data engine, and the regional text in the content control is filled, for example,

Control ctrl1＝Document.ContentControls[ctrl.ID]；

ctrl1.range. text ═ XX hospital … …

The electronic medical record generation interface obtained after the electronic medical record template is automatically filled can be as shown in fig. 6.

By the embodiment, the operation required for generating the electronic medical record can be simplified, the time consumption required for generating the electronic medical record is reduced, and the generation efficiency of the electronic medical record is improved by acquiring the preset object data and automatically writing part of the content control.

As an alternative embodiment, generating the target electronic medical record of the target object includes:

s41, acquiring a plurality of target object data corresponding to a plurality of content controls, wherein the plurality of content controls correspond to the plurality of target object data one to one;

s42, performing data validity check and data integrity check on the target object data;

and S43, generating the target electronic medical record of the target object under the condition that the data validity check and the data integrity check are passed.

In order to generate a target electronic medical record corresponding to a target object, a plurality of target object data corresponding to a plurality of content controls may be first acquired, and the plurality of content controls are in one-to-one correspondence with the plurality of target object data.

After the plurality of target object data are acquired, the plurality of target object data may be verified, the verification operation may be performed by the terminal device or a server communicatively connected to the terminal device, and the verification may include, but is not limited to, at least one of: and verifying the legality and the integrity.

If the plurality of target object data are legal and the plurality of target object data are complete (no missing object data), the terminal device may generate a target electronic medical record of the target object.

Through the embodiment, the legality and integrity of the input object data are verified, so that the integrity and accuracy of the acquired data can be improved, and the complexity of follow-up statistics and research is reduced.

As an optional embodiment, after generating the target electronic medical record of the target object, the method further includes:

s51, generating target structured data corresponding to the target electronic medical record, wherein the target structured data is used for representing the corresponding relation between the control identification of each content control and the target object data corresponding to each content control;

and S52, sending the target structured data to the first server for storage.

While generating the target electronic medical record of the target object, structured data corresponding to the target electronic medical record, that is, target structured data, may also be generated, where the target structured data is used to represent a correspondence between the control identifier of each content control and the target object data corresponding to each content control. The target structured data may be stored in the form of a structured file, and an example of the target structured file may be as shown in fig. 7, where fig. 7 is only an exemplary illustration of the target structured file, and does not limit the specific content and the form of the content in the target structured file.

The difference between the structured file of the electronic medical record template and the structured file of the target electronic medical record (the electronic medical record document of the patient) can be as follows: the electronic medical record template is < Field > </Field >, and the electronic medical record document of the patient is < Field > XX (patient identification) </Field >.

After the target structured data is obtained, the terminal device can send the target structured data to the first database for storage, so that the stored data can be better used for analysis and statistics.

Through the embodiment, the efficiency of data analysis and statistics can be improved by generating and storing the structured file of the electronic medical record.

s61, configuring target medical record data in the target electronic medical record into a locked state, wherein the target medical record data comprises target object data corresponding to each content control, and the locked state is a state which is not allowed to be modified;

and S62, sending the target electronic medical record to a second server for storage.

In order to improve the reliability of the target electronic medical record, the terminal device can configure the target medical record data in the target electronic medical record into a locked state. The target medical record data is generated medical record data and can comprise target object data corresponding to each content control; and the locked state is a state that is not allowed to be modified.

Optionally, in order to ensure that the electronic medical record can be modified in special cases and that the modification is recorded, the target electronic medical record can be configured to be in a revision state, and in the revision state, the modified content and information of a person (e.g., reviewer) related to the modification can be recorded for information tracing.

The target electronic medical record can record all treatment records of the target object; the medical records of the target object in one hospital can be recorded, in this case, the medical records of the target object in different hospitals can be saved by using different electronic medical records; it is also possible to record only one visit record of the target subject in one hospital, in which case the visit record of each visit of the target subject can be saved with a different electronic medical record. This is not limited in this embodiment.

After the target medical record data in the target electronic medical record is configured to be in the locked state, the terminal device can send the target electronic medical record to the second server for storage, so that a doctor can check the historical visit record of the patient by calling the target electronic medical record.

By the embodiment, the reliability of the electronic medical record can be improved by configuring the existing medical record into the locking state.

The following explains a method for generating an electronic medical record in the embodiment of the present application with reference to an alternative example. In this example, the target document application is WPS and the structured data is XML structured information.

In order to solve the problem of complex writing of the electronic medical record, the WPS can be used as an electronic medical record editor, and can be used as a common office document to be accepted and used proficiently by doctors. Moreover, by storing XML structural information corresponding to the electronic medical record, the efficiency of verifying and applying the data can be improved. In addition, the problem that the electronic medical record files depend on respective software can be effectively solved, so that the electronic medical record files can be better shared.

With reference to fig. 8 and fig. 9, the flow of the method for generating an electronic medical record in this example may include the following steps:

and S902, making a medical document template by combining the content control.

The content widget can be used as a structured widget, and the insertion and deletion of the content widget can be controlled in a program mode by performing abstract integration on the content widget in the WPS. The WPS function can be applied, and a professional medical document template (electronic medical record template) can be manufactured by combining the content control, so that a WPS file and XML structured information of the medical document template can be generated.

And step S904, calling the electronic medical record template and directly loading part of information into the content control when the patient is generated.

When the duration of a disease is generated, the WPS file and the XML structured information can be loaded firstly; then, the information is loaded directly into the content control through a corresponding algorithm (an algorithm that analyzes the XML structured information and the preset object data).

And step S906, inputting the patient information into the content control of the electronic medical record template, and saving the WPS file and the corresponding XML file.

The WPS file may be saved for the duration of the save. And then, generating XML structured data of the medical record file by analyzing the WPS file and processing the content control, and storing the XML file. In structured expression, clinical data can be recorded at hospital admission to a medical facility for structured deconstruction and reorganization.

By using the WPS as the electronic medical record editor and the content control as the data structuring basis of the WPS electronic medical record editor, a doctor can conveniently master the use of the electronic medical record and the writing efficiency is improved; meanwhile, data can be better shared, and only the WPS document can be checked; in addition, the problem of electronic medical record structuralization can be perfectly solved, and stored data can be better analyzed and counted.

It should be noted that, for simplicity of description, the above-mentioned method embodiments are described as a series of acts or combination of acts, but those skilled in the art will recognize that the present application is not limited by the order of acts described, as some steps may occur in other orders or concurrently depending on the application. Further, those skilled in the art should also appreciate that the embodiments described in the specification are preferred embodiments and that the acts and modules referred to are not necessarily required in this application.

Through the above description of the embodiments, those skilled in the art can clearly understand that the method according to the above embodiments can be implemented by software plus a necessary general hardware platform, and certainly can also be implemented by hardware, but the former is a better implementation mode in many cases. Based on such understanding, the technical solutions of the present application may be embodied in the form of a software product, which is stored in a storage medium (e.g., ROM/RAM, magnetic disk, optical disk) and includes instructions for enabling a terminal device (e.g., a mobile phone, a computer, a server, or a network device) to execute the method according to the embodiments of the present application.

According to another aspect of the embodiment of the application, an electronic medical record generation device for implementing the electronic medical record generation method is also provided. Fig. 10 is a schematic diagram of an alternative apparatus for generating an electronic medical record according to an embodiment of the present application, and as shown in fig. 10, the apparatus may include:

(1) the first display unit 1002 is configured to display an electronic medical record template in a target display area of an electronic medical record editor, where the electronic medical record template is a template displayed by using a target document application integrated in the electronic medical record editor, and the electronic medical record template includes multiple content controls allowing information input;

(2) a detecting unit 1004, connected to the first display unit 1002, for detecting a plurality of input operations performed on a plurality of content controls, where each of the plurality of input operations is used to input one type of target object data corresponding to a target object in one of the plurality of content controls;

(3) the first generating unit 1006 is connected to the first display unit 1002, and configured to generate a target electronic medical record of a target object in response to multiple input operations, where the target electronic medical record includes target object data corresponding to each content control of multiple content controls.

It should be noted that the first display unit 1002 in this embodiment may be configured to execute the step S202, the detection unit 1004 in this embodiment may be configured to execute the step S204, and the first generation unit 1006 in this embodiment may be configured to execute the step S206.

Through the module, an electronic medical record template is displayed in a target display area of an electronic medical record editor, wherein the electronic medical record template is displayed by using a target document application integrated in the electronic medical record editor, and the electronic medical record template comprises a plurality of content controls allowing information input; detecting a plurality of input operations executed on a plurality of content controls, wherein each input operation in the plurality of input operations is used for inputting one type of target object data corresponding to a target object in one content control in the plurality of content controls; the target electronic medical record of the target object is generated in response to the plurality of input operations, wherein the target electronic medical record comprises target object data corresponding to each content control in the plurality of content controls, the problem that the electronic medical record acquisition mode in the related technology is high in labor cost due to the fact that the acquisition process is complex is solved, the generation efficiency of the electronic medical record is improved, and labor cost is saved.

As an alternative embodiment, the apparatus further comprises:

the second display unit is used for displaying the template configuration area of the electronic medical record template in the template configuration interface of the target equipment before displaying the electronic medical record template in the target display area of the electronic medical record editor;

the template configuration device comprises an adding unit, a setting unit and a processing unit, wherein the adding unit is used for adding a plurality of data elements in a template configuration area, the data elements correspond to a plurality of content controls one by one, and each data element in the data elements comprises a control identification of each content control corresponding to each data element and an input frame of each content control;

and the second generation unit is used for generating an electronic medical record template containing a plurality of content controls according to the plurality of data elements, wherein the electronic medical record template only allows information input in the input box of each content control.

As an alternative embodiment, the first display unit 1002 includes:

the detection module is used for detecting a trigger operation executed on a first interface of the electronic medical record editor, wherein the trigger operation is used for triggering generation of a target electronic medical record corresponding to a target object;

and the display module is used for responding to the trigger operation, calling the electronic medical record template and displaying the electronic medical record template in a target display area of a second interface of the electronic medical record editor.

As an alternative embodiment, the apparatus further comprises:

the electronic medical record editor comprises an acquisition unit, a display unit and a display unit, wherein the acquisition unit is used for acquiring preset object data corresponding to a target object after an electronic medical record template is displayed in a target display area of the electronic medical record editor, and the preset object data is one or more object data of the preset target object;

the determining unit is used for determining a target content control corresponding to the preset object data from the plurality of content controls;

and the input unit is used for automatically inputting preset object data in the target content control.

As an alternative embodiment, the first generating unit 1006 includes:

the system comprises an acquisition module, a display module and a display module, wherein the acquisition module is used for acquiring a plurality of target object data corresponding to a plurality of content controls, and the content controls correspond to the target object data one to one;

the verification module is used for performing data validity verification and data integrity verification on the plurality of target object data;

and the generating module is used for generating the target electronic medical record of the target object under the condition that both the data validity check and the data integrity check pass.

As an alternative embodiment, the apparatus further comprises:

a third generating unit, configured to generate target structured data corresponding to a target electronic medical record after generating the target electronic medical record of the target object, where the target structured data is used to represent a correspondence between a control identifier of each content control and target object data corresponding to each content control;

and the first sending unit is used for sending the target structured data to the first server for storage.

As an alternative embodiment, the apparatus further comprises:

the configuration unit is used for configuring target medical record data in the target electronic medical record into a locked state after the target electronic medical record of the target object is generated, wherein the target medical record data comprises target object data corresponding to each content control, and the locked state is a state which is not allowed to be modified;

and the second sending unit is used for sending the target electronic medical record to a second server for storage.

It should be noted here that the modules described above are the same as the examples and application scenarios implemented by the corresponding steps, but are not limited to the disclosure of the above embodiments. It should be noted that the modules described above as a part of the apparatus may be operated in a hardware environment as shown in fig. 1, and may be implemented by software, or may be implemented by hardware, where the hardware environment includes a network environment.

According to another aspect of the embodiment of the present application, there is also provided an electronic device for implementing the method for generating an electronic medical record, where the electronic device may be a server, a terminal, or a combination thereof.

Fig. 11 is a block diagram of an alternative electronic device according to an embodiment of the present application, and as shown in fig. 11, the electronic device includes a memory 1102 and a processor 1104, where the memory 1102 stores a computer program, and the processor 1104 is configured to execute steps of any one of the method embodiments described above through the computer program.

Optionally, in this embodiment, the electronic apparatus may be located in at least one network device of a plurality of network devices of a computer network.

Optionally, in this embodiment, the processor may be configured to execute the following steps by a computer program:

s1, displaying an electronic medical record template in a target display area of the electronic medical record editor, wherein the electronic medical record template is displayed by using a target document application integrated in the electronic medical record editor, and the electronic medical record template comprises a plurality of content controls allowing information input;

s2, detecting a plurality of input operations executed on a plurality of content controls, wherein each input operation in the plurality of input operations is used for inputting one type of target object data corresponding to a target object in one content control in the plurality of content controls;

and S3, responding to the plurality of input operations, and generating a target electronic medical record of the target object, wherein the target electronic medical record contains target object data corresponding to each content control in the plurality of content controls.

The memory 1102 may be configured to store software programs and modules, such as program instructions/modules corresponding to the method and apparatus for generating an electronic medical record in the embodiment of the present invention, and the processor 1104 executes various functional applications and data processing by running the software programs and modules stored in the memory 1102, so as to implement the method for generating an electronic medical record. The memory 1102 may include high-speed random access memory, and may also include non-volatile memory, such as one or more magnetic storage devices, flash memory, or other non-volatile solid-state memory. In some examples, the memory 1102 can further include memory located remotely from the processor 1104 and such remote memory can be coupled to the terminal via a network. Examples of such networks include, but are not limited to, the internet, intranets, local area networks, mobile communication networks, and combinations thereof.

As an example, as shown in fig. 11, the memory 1102 may include, but is not limited to, a first display unit 1002, a detection unit 1004, and a first generation unit 1006 in the electronic medical record generation apparatus. In addition, the electronic medical record generating device may further include, but is not limited to, other module units in the electronic medical record generating device, which is not described in detail in this example.

Optionally, the transmitting device 1106 is used for receiving or transmitting data via a network. Examples of the network may include a wired network and a wireless network. In one example, the transmission device 1106 includes a Network adapter (NIC) that can be connected to a router via a Network cable to communicate with the internet or a local area Network. In one example, the transmission device 1106 is a Radio Frequency (RF) module, which is used for communicating with the internet in a wireless manner.

In addition, the electronic device further includes: a connection bus 1108 for connecting the various module components of the electronic device.

Optionally, the specific examples in this embodiment may refer to the examples described in the above embodiments, and this embodiment is not described herein again.

It can be understood by those skilled in the art that the structure shown in fig. 11 is only an illustration, and the device implementing the method for generating an electronic medical record may be a terminal device, and the terminal device may be a terminal device such as a smart phone (e.g., an Android phone, an iOS phone, etc.), a tablet computer, a palm computer, a Mobile Internet Device (MID), a PAD, and the like. Fig. 11 is a diagram illustrating a structure of the electronic device. For example, the terminal device may also include more or fewer components (e.g., network interfaces, display devices, etc.) than shown in FIG. 11, or have a different configuration than shown in FIG. 11.

Those skilled in the art will appreciate that all or part of the steps in the methods of the above embodiments may be implemented by a program instructing hardware associated with the terminal device, where the program may be stored in a computer-readable storage medium, and the storage medium may include: flash disks, Read-Only memories (ROMs), Random Access Memories (RAMs), magnetic or optical disks, and the like.

According to still another aspect of an embodiment of the present application, there is also provided a storage medium. Optionally, in this embodiment, the storage medium may be used to execute a program code of a method for generating an electronic medical record.

Optionally, in this embodiment, the storage medium may be located on at least one of a plurality of network devices in a network shown in the above embodiment.

Optionally, the specific example in this embodiment may refer to the example described in the above embodiment, which is not described again in this embodiment.

Optionally, in this embodiment, the storage medium may include, but is not limited to: various media capable of storing program codes, such as a U disk, a ROM, a RAM, a removable hard disk, a magnetic disk, or an optical disk.

The above-mentioned serial numbers of the embodiments of the present application are merely for description and do not represent the merits of the embodiments.

The integrated unit in the above embodiments, if implemented in the form of a software functional unit and sold or used as a separate product, may be stored in the above computer-readable storage medium. Based on such understanding, the technical solution of the present application may be substantially implemented or a part of or all or part of the technical solution contributing to the prior art may be embodied in the form of a software product stored in a storage medium, and including instructions for causing one or more computer devices (which may be personal computers, servers, network devices, or the like) to execute all or part of the steps of the method described in the embodiments of the present application.

In the above embodiments of the present application, the descriptions of the respective embodiments have respective emphasis, and for parts that are not described in detail in a certain embodiment, reference may be made to related descriptions of other embodiments.

In the several embodiments provided in the present application, it should be understood that the disclosed client may be implemented in other manners. The above-described embodiments of the apparatus are merely illustrative, and for example, the division of the units is only one type of division of logical functions, and there may be other divisions when actually implemented, for example, a plurality of units or components may be combined or may be integrated into another system, or some features may be omitted, or not executed. In addition, the shown or discussed mutual coupling or direct coupling or communication connection may be an indirect coupling or communication connection through some interfaces, units or modules, and may be in an electrical or other form.

The units described as separate parts may or may not be physically separate, and parts displayed as units may or may not be physical units, may be located in one place, or may be distributed on a plurality of network units. Some or all of the units may be selected according to actual needs to achieve the purpose of the solution provided in the embodiment.

In addition, functional units in the embodiments of the present application may be integrated into one processing unit, or each unit may exist alone physically, or two or more units are integrated into one unit. The integrated unit can be realized in a form of hardware, and can also be realized in a form of a software functional unit.

The foregoing is only a preferred embodiment of the present application and it should be noted that those skilled in the art can make several improvements and modifications without departing from the principle of the present application, and these improvements and modifications should also be considered as the protection scope of the present application.

Claims

1. A method for generating an electronic medical record is characterized by comprising the following steps:

displaying an electronic medical record template in a target display area of an electronic medical record editor, wherein the electronic medical record template is displayed by using a target document application integrated in the electronic medical record editor, and the electronic medical record template comprises a plurality of content controls allowing information input;

detecting a plurality of input operations performed on the plurality of content controls, wherein each input operation in the plurality of input operations is used for inputting one type of target object data corresponding to a target object in one content control in the plurality of content controls;

and responding to the plurality of input operations, and generating a target electronic medical record of the target object, wherein the target electronic medical record contains the target object data corresponding to each content control in the plurality of content controls.

2. The method of claim 1, wherein prior to displaying the electronic medical record template within the target display area of the electronic medical record editor, the method further comprises:

displaying a template configuration area of the electronic medical record template in a template configuration interface of target equipment;

adding a plurality of data elements in the template configuration area, wherein the data elements correspond to the content controls one by one, and each data element in the data elements contains a control identification of each content control corresponding to the data element and an input box of each content control;

and generating the electronic medical record template containing the plurality of content controls according to the plurality of data elements, wherein the electronic medical record template only allows information input in the input box of each content control.

3. The method of claim 1, wherein displaying the electronic medical record template within the target display area of the electronic medical record editor comprises:

detecting a trigger operation executed on a first interface of the electronic medical record editor, wherein the trigger operation is used for triggering generation of the target electronic medical record corresponding to the target object;

and responding to the triggering operation, calling the electronic medical record template, and displaying the electronic medical record template in the target display area of a second interface of the electronic medical record editor.

4. The method of claim 3, wherein after displaying the electronic medical record template within the target display area of the electronic medical record editor, the method further comprises:

acquiring preset object data corresponding to the target object, wherein the preset object data is one or more object data of the target object configured in advance;

determining a target content control corresponding to the preset object data from the plurality of content controls;

and automatically inputting the preset object data in the target content control.

5. The method of claim 1, wherein generating the target electronic medical record of the target object comprises:

acquiring a plurality of target object data corresponding to the plurality of content controls, wherein the plurality of content controls correspond to the plurality of target object data one to one;

performing data validity check and data integrity check on a plurality of target object data;

and under the condition that the data validity check and the data integrity check both pass, generating the target electronic medical record of the target object.

6. The method of claim 1, wherein after generating the target electronic medical record of the target object, the method further comprises:

generating target structured data corresponding to the target electronic medical record, wherein the target structured data is used for representing a corresponding relation between the control identification of each content control and the target object data corresponding to each content control;

and sending the target structured data to a first server for storage.

7. The method of any of claims 1-6, wherein after generating the target electronic medical record of the target object, the method further comprises:

configuring target medical record data in the target electronic medical record into a locked state, wherein the target medical record data comprises the target object data corresponding to each content control, and the locked state is a state which is not allowed to be modified;

and sending the target electronic medical record to a second server for storage.

8. An apparatus for generating an electronic medical record, comprising:

the electronic medical record editor comprises a first display unit, a second display unit and a display unit, wherein the first display unit is used for displaying an electronic medical record template in a target display area of the electronic medical record editor, the electronic medical record template is displayed by using a target document application integrated in the electronic medical record editor, and the electronic medical record template comprises a plurality of content controls allowing information input;

a detecting unit, configured to detect a plurality of input operations performed on the plurality of content controls, where each of the plurality of input operations is used to input one type of target object data corresponding to a target object in one of the plurality of content controls;

and the first generating unit is used for responding to the plurality of input operations and generating a target electronic medical record of the target object, wherein the target electronic medical record contains the target object data corresponding to each content control in the plurality of content controls.

9. A computer-readable storage medium, in which a computer program is stored, wherein the computer program is configured to carry out the method of any one of claims 1 to 7 when executed.

10. An electronic device comprising a memory and a processor, characterized in that the memory has stored therein a computer program, the processor being arranged to execute the method of any of claims 1 to 7 by means of the computer program.