CN101051337A - Electronic medical record system for outpatient service - Google Patents
Electronic medical record system for outpatient service Download PDFInfo
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- CN101051337A CN101051337A CNA200710099572XA CN200710099572A CN101051337A CN 101051337 A CN101051337 A CN 101051337A CN A200710099572X A CNA200710099572X A CN A200710099572XA CN 200710099572 A CN200710099572 A CN 200710099572A CN 101051337 A CN101051337 A CN 101051337A
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Abstract
An electronic medical record system used at clinic comprises server formed by PACS server and HIS server, and doctor operation-station terminal computer connected with said server through network. It is featured as using PACS server to realize C-Move SCP service and C-store SCP service of DICOM standard as well as management of PACS system for storing medical record information in DICOM file form, using HIS server to store basic information of patient, using doctor operation-station terminal computer to set up and to query as well as to edit electronic medical record then utilizing DICOM standard and PACS server to carry out information exchange.
Description
Technical field
The present invention relates to medical areas of information technology, relate in particular to a kind of electronic medical record system that is applied to outpatient service with electronic signature and file administration function.
Background technology
Along with popularizing and the continuous expansion of hospital size of computing machine, patient's electronic medical record management becomes more and more important.The electronic medical record that present most hospital comes into operation mainly is based on Word document, relevant database and XML database.
Wherein, Word document is the most original electronic medical record form, because it does not possess the file administration function, so in a sense, this scheme is not real electronic medical record.The scheme of relevant database is used the most extensive, and hospital information system in the market (being the HIS system) nearly all has some case taking functions concurrently.It is found that in use medical record is that a kind of tree structure of complexity, particularly Medical Record are complicated more, is difficult to express clearly with simple relevant database form.Come out in the electronic medical record that is based on the XML database is corresponding.
More than these electronic medical records all have a common defective, do not have doctor's electronic signature exactly.And the medical record that does not have the doctor to sign is all to be invalid from management view or from the law angle.
In the medical information technology, PACS system (Picture Archiving andCommunication Systems image file and communication system) is the technology that is developing, its impetus is in the ascendant, the PACS system is the technology that is used to provide the medical image management, is primarily aimed at image such as CT, nuclear-magnetism and the X ray etc. of dept. of radiology.The article of relevant PACS is a lot, but all at image, also this technology is not used for the precedent of outpatient service electronic medical record at present.
DICOM (Digital Imaging and Communications medical digitized video of in Medicine and communications protocol) be between the medical information system or infosystem and medical image equipment between carry out communication communications protocol, this agreement has been stipulated communication, file, information security, comprises digital signature in information security.Usually, when hospital uses in reality, all to provide the literal report, in dicom standard, define information object about the descriptive text report by the radiologist at each dept. of radiology's image.This patent uses these information objects that define in the dicom standard as electronic medical record, does not rely on any image, but independently produces according to the needs of first visit or further consultation.
This patent also relates to HIS system (Hospital Information System hospital information system) this patent and the HIS system is called and invoked relation, or perhaps interface relationship, does not comprise the content of HIS system.Usually the HIS system comprises information such as patient information, medicine information, pay imformation and logistics support, the electronic medical record system that this patent makes up is just write diagnosis and treatment record, and guarantee the non repudiation of medical record with electronic signature technology, can obtain patient's essential information from the HIS system by interface in case of necessity, as name sex etc.
Summary of the invention
The present invention has realized having the electronic medical record system that is applicable to outpatient service of digital signature function and file administration function.
The electronic medical record system that is used for outpatient service of the present invention is based on PACS system architecture and dicom standard, comprises the server and the doctor workstation terminal computer that are connected by network; Wherein server comprises PACS server and HIS server, described PACS server is realized the management of service of dicom standard specified standard and PACS system, with DICOM document form storage medical record information, described HIS server stores patient essential information, the establishment of described doctor workstation terminal computer, inquiry, editing electronic medical record are also carried out digital signature to medical record, carry out message exchange by dicom standard and PACS server.
Described PACS server and HIS server can be merged into a server.
Described DICOM file comprises text file or image file.
Described PACS server can adopt relevant database as auxiliary PACS information management.
Obtain patient's essential information or manually produce patient's essential information and call specific program or service-specific generate to be checked and sequence identifier from described HIS server by the doctor workstation terminal computer, create the first visit medical record and send into described PACS server with dicom standard.
Described doctor workstation terminal computer is realized obtaining and submitting to medical record by carrying out message exchange with the PACS server.
Described doctor workstation terminal computer to medical record edit, management and digital signature.
Compared with prior art, the invention has the beneficial effects as follows: the present invention is by introducing ripe DICOM and PACS technology, realized the function of the typing of outpatient service medical record, file administration and digital signature, can make the realization electronic medical record management truly of outpatient service section office, clinic or a clinic, whole system is with low cost, do not need to add extra equipment, be not only applicable to large hospital and be applicable to small hospital of community and clinic.
Description of drawings
Fig. 1 is that the electronic medical record system that is used for outpatient service is formed the structure intention.
Embodiment
Now reaching embodiment in conjunction with the accompanying drawings is described in further detail the present invention.
Fig. 1 is that the electronic medical record system that is used for outpatient service is formed the structure intention.With reference to figure 1, the electronic medical record system that is used for outpatient service of the present invention is based on that PACS system architecture and dicom standard set up.On structure, comprise PACS server 11, HIS server 12 and doctor workstation terminal computer 15,16,17,18, also comprise LAN (Local Area Network) 14 and printer 13.Connect by LAN (Local Area Network) between PACS server and HIS server, printer and the doctor workstation terminal computer 15～18, carry out data communication.Wherein, store patient's essential information in the HIS server 12; PACS server 11 is realized the C-Move SCP service of dicom standard, the management of C-Store SCP service and PACS system, preservation is with the patient's medical record information and the digital signature information of the storage of DICOM document form, in order to accelerate the retrieval rate of PACS management, can use relevant database to comprise off-line and online record as auxiliary PACS information management, but relevant database herein is only as the supplementary means that improves speed, complete information is all preserved in the DICOM file, if can regenerate after the content in the relevant database is deleted or loses; The doctor workstation terminal computer makes the clinician can create and manage medical record on the one hand, can also inquire about, obtain and send the DICOM file or the DICOM image file that contain medical record information by dicom standard and PACS systems exchange information.
The step of creating the first visit medical record by the present invention comprises:
1. the doctor workstation terminal computer perhaps manually produces patient's essential information by the doctor from the acquisition patient's of HIS system essential information, calls specific program or service-specific simultaneously and generates inspection and sequence identifier (Study and Series);
2. this patient's first visit medical record is created and edited to the doctor workstation terminal computer;
3. the doctor workstation terminal computer sends to the PACS server with above-mentioned first visit medical record in accordance with dicom standard and files.
At same patient, later treatment set up by the first visit medical record and idagnostic logout is the further consultation medical record, can carry out appending of diagnostic message to the further consultation medical record, revises and digital signature, and it should satisfy following rule:
1. any further consultation medical record of patient is in case just can not revise through digital signature;
2. any doctor can append diagnostic message;
3. can only revise by the establishment doctor of medical record or the leader of its section office without the further consultation medical record of digital signature, and this medical record can only be signed by creating the doctor.
The establishment of patient's further consultation medical record and use step are as follows:
1. the doctor workstation terminal computer calls this patient's medical record file to the PACS server requests after obtaining patient's patient's identification number;
2.PACS server sends the medical record file of its request to above-mentioned doctor workstation terminal computer;
3. the doctor workstation terminal computer shows the medical record of receiving or edits;
4. can append new medical record as needing;
5. sending the medical record file of edited or new establishment back to the PACS server files.
For small-sized hospital or clinic, HIS server 11 and PACS server 12 can be combined use.
The above embodiment only is the preferred embodiments of the present invention; the invention is not restricted to the foregoing description; for persons skilled in the art; the any conspicuous change of under the prerequisite that does not deviate from the principle of the invention it being done all belongs to the protection domain of design of the present invention and claims.
Claims (7)
1. an electronic medical record system that is used for outpatient service is characterized in that: based on PACS system architecture and dicom standard, comprise the server and the doctor workstation terminal computer that are connected by network; Wherein server comprises PACS server and HIS server, described PACS server is realized the management of service of dicom standard specified standard and PACS system, with DICOM document form storage medical record information, described HIS server stores patient essential information, the establishment of described doctor workstation terminal computer, inquiry, editing electronic medical record are also carried out digital signature to medical record, carry out message exchange by dicom standard and PACS server.
2. the electronic medical record system that is used for outpatient service according to claim 1 is characterized in that: described PACS server and HIS server can be merged into a server.
3. the electronic medical record system that is used for outpatient service according to claim 1 is characterized in that: described DICOM file comprises text file or image file.
4. the electronic medical record system that is used for outpatient service according to claim 1 is characterized in that: described PACS server can adopt relevant database as auxiliary PACS information management.
5. the electronic medical record system that is used for outpatient service according to claim 1, it is characterized in that: described doctor workstation terminal computer obtains patient's essential information or manually produces patient's essential information and call specific program or service-specific generate to be checked and sequence identifier from described HIS server, creates the first visit medical record and sends into described PACS server with dicom standard.
6. the electronic medical record system that is used for outpatient service according to claim 1 is characterized in that: described doctor workstation terminal computer is realized obtaining and submitting to medical record by carrying out message exchange with the PACS server.
7. the electronic medical record system that is used for outpatient service according to claim 1 is characterized in that: described doctor workstation terminal computer to medical record edit, management and digital signature.
Priority Applications (1)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CNA200710099572XA CN101051337A (en) | 2007-05-24 | 2007-05-24 | Electronic medical record system for outpatient service |
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| Application Number | Priority Date | Filing Date | Title |
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| CNA200710099572XA CN101051337A (en) | 2007-05-24 | 2007-05-24 | Electronic medical record system for outpatient service |
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| CN101051337A true CN101051337A (en) | 2007-10-10 |
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Cited By (10)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN102419797A (en) * | 2011-12-05 | 2012-04-18 | 苏州汉清投资管理有限公司 | Medical information system |
| CN102483816A (en) * | 2009-09-18 | 2012-05-30 | 泰尔茂株式会社 | Medical information management system |
| CN102696033A (en) * | 2010-01-08 | 2012-09-26 | 柯尼卡美能达医疗印刷器材株式会社 | Medical-use information processing device and program |
| CN103049582A (en) * | 2013-01-25 | 2013-04-17 | 苏州皓琪信息科技有限公司 | Automatic digital imaging and communications in medicine (DICOM) medical image data migration system and method |
| CN101782852B (en) * | 2010-01-19 | 2015-01-07 | 西安华海医疗信息技术股份有限公司 | Method for extracting computer screen information for medical administration |
| CN104994333A (en) * | 2015-05-29 | 2015-10-21 | 上海京颐科技股份有限公司 | Medical image transfer device, client terminal, transmission system and transmission method thereof |
| CN105589624A (en) * | 2015-12-23 | 2016-05-18 | 北京医佳医网络技术有限公司 | Booking register-based floating window editing method |
| CN105844566A (en) * | 2016-03-25 | 2016-08-10 | 东华软件股份公司 | Electronic medical record filing management system and electronic medical record filing management method |
| WO2017128618A1 (en) * | 2016-01-26 | 2017-08-03 | 深圳市科曼医疗设备有限公司 | Medical diagnosis electronic report generation method and system |
| CN109949884A (en) * | 2019-02-26 | 2019-06-28 | 四川旅鸽科技有限公司 | The with no paper generation method of case of hospital information and device |
-
2007
- 2007-05-24 CN CNA200710099572XA patent/CN101051337A/en active Pending
Cited By (11)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN102483816A (en) * | 2009-09-18 | 2012-05-30 | 泰尔茂株式会社 | Medical information management system |
| CN102696033A (en) * | 2010-01-08 | 2012-09-26 | 柯尼卡美能达医疗印刷器材株式会社 | Medical-use information processing device and program |
| CN101782852B (en) * | 2010-01-19 | 2015-01-07 | 西安华海医疗信息技术股份有限公司 | Method for extracting computer screen information for medical administration |
| CN102419797A (en) * | 2011-12-05 | 2012-04-18 | 苏州汉清投资管理有限公司 | Medical information system |
| CN103049582A (en) * | 2013-01-25 | 2013-04-17 | 苏州皓琪信息科技有限公司 | Automatic digital imaging and communications in medicine (DICOM) medical image data migration system and method |
| CN104994333A (en) * | 2015-05-29 | 2015-10-21 | 上海京颐科技股份有限公司 | Medical image transfer device, client terminal, transmission system and transmission method thereof |
| CN105589624A (en) * | 2015-12-23 | 2016-05-18 | 北京医佳医网络技术有限公司 | Booking register-based floating window editing method |
| CN105589624B (en) * | 2015-12-23 | 2018-05-29 | 北京医佳医网络技术有限公司 | The floating frame edit methods registered based on reservation |
| WO2017128618A1 (en) * | 2016-01-26 | 2017-08-03 | 深圳市科曼医疗设备有限公司 | Medical diagnosis electronic report generation method and system |
| CN105844566A (en) * | 2016-03-25 | 2016-08-10 | 东华软件股份公司 | Electronic medical record filing management system and electronic medical record filing management method |
| CN109949884A (en) * | 2019-02-26 | 2019-06-28 | 四川旅鸽科技有限公司 | The with no paper generation method of case of hospital information and device |
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