CN101236579A - Dynamic structured electronic patient history - Google Patents
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- CN101236579A CN101236579A CNA200810007256XA CN200810007256A CN101236579A CN 101236579 A CN101236579 A CN 101236579A CN A200810007256X A CNA200810007256X A CN A200810007256XA CN 200810007256 A CN200810007256 A CN 200810007256A CN 101236579 A CN101236579 A CN 101236579A
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Abstract
The invention provides a method for realizing electronic medical history and a device thereof; the method comprises the following steps of: element construction, chapter construction, element embedding and medical history construction; a format of the element construction is a standard format for inputting diagnosis and treatment data which can be standardized; a format of the chapter construction is a free format for inputting diagnosis and treatment information in a natural language form; a format of the medical history construction consists of chapters for inputting diagnosis and treatment records. The invention realizes the fusion of natural texts and structured texts of the electronic medical history and can meets the requirements of stationarytype and flexibility simultaneously.
Description
Technical field
The present invention relates to medical field, in particular to the implementation method and the device of electronic health record.
Background technology
Electronic health record (Electronic Medical Record is abbreviated as EMR) is the relevant personal health state managed in electronic mode and the information of health care behavior, relates to collection, storage, transmission, processing and the utilization etc. of patient information.Can in medical treatment, replace the paper case history, the service that surmounts the paper case history is provided, satisfy medical treatment, law and regulatory requirement as the main information source.
Initial electronic health record is that the case history text is carried out the electronics storage, the variation that removes storage and ways of writing, and any variation does not take place in case history itself.Present domestic electronic health record product can be divided into research application and clinical practice two classes, and this two series products has significant different in technology and function aspects.Being used for clinical electronic health record to support that free text typing, typing template and key word are feature, is to adopt this pattern in full.The electronic health record generation that is used for scientific research to be supporting that semi-structured document, XML are feature, selects typing based on format case history and limited key word of support matrix, is to adopt the structurized typing pattern of all forms.
In realizing process of the present invention, the inventor finds that medical science is a kind of theory and experience subject combining, no matter is scientific research field or clinical field, and the demand of existing a lot of theoretical general characterization has the demand of a lot of personalizations again; And no matter the electronic health record of above-mentioned two kinds of technology modes is applied to scientific research and still is applied to clinically, all has fixed and the contradiction dirigibility requirement at least.Though the electronic health record of the structurized typing pattern of employing all forms is standard very, is convenient to extract data, lacks dirigibility fully, even be applied to the less occasion of this individual demand of scientific research, also dirigibility is too poor; Though and the electronic health record of employing full text pattern originally is very flexible, can satisfy the individual demand of clinical practice, even be applied to the less occasion of clinical this general character demand, also standardization is too poor.
Therefore require the design of electronic health record satisfying the requirement that to satisfy the flexible processing of doctor on the basis of standardization simultaneously again, traditional electronic health record processing mode or standard but dumb very, perhaps very flexible but lack of standardization, can't solve fixed and the contradiction dirigibility requirement.
Summary of the invention
The present invention aims to provide a kind of implementation method of electronic health record, and the electronic health record that can solve prior art can't satisfy the fixed problem that requires with dirigibility simultaneously.
In an embodiment of the present invention, provide a kind of implementation method of electronic health record, may further comprise the steps: make up element, its form is a standard format, and being used for typing can standardized diagnosis and treatment data; Make up chapters and sections, its form is a free-format, is used for the diagnosis and treatment information of typing natural language form, and embeds element; And the structure case history, it is made of chapters and sections, is used for the typing diagnosis and therapy recording.
Preferably, the form of element comprises: show attribute, be used for the exhibition method of indicator element, title, and the relation between other elements; And data attribute, be used for the designation data source.
Preferably, also comprise: element stencil design device is provided, is used to accept user's definition, to make up the format of element.
Preferably, can standardized diagnosis and treatment data comprise following at least one: the character of the symptom of patient name, sex, age, height, body weight, morbidity, site of pathological change, disease time, disease symptom, health check-up index.
Preferably, also comprise: make up the chapters and sections template of chapters and sections in advance, wherein, various chapters and sections templates embed different elements according to different types of diagnosis and treatment behavior.
Preferably, also comprise: chapters and sections stencil design device is provided, is used to accept user's definition, to make up the new chapters and sections template of chapters and sections.
Preferably, also comprise: make up the case history template of case history in advance, wherein, various case history templates are made of different chapters and sections according to dissimilar diagnosis and therapy recordings.
Preferably, also comprise: case history stencil design device is provided, is used to accept user's definition, to make up the new case history template of case history.
Preferably, also comprise: make up database, be used for preserving and management element, template and case history.
Preferably, make up case history and also comprise: template manager is provided, and template manager is used for and will is summarized by the natural language of user's typing and conclude, and adopts the medical treatment and the diagnosis term of standard, is made into general and case history template each training disease that calls for specialized treatment special use; The medical record writing device is provided, and the medical record writing device is used to accept the modification that the user carries out case history; The case history print manager is provided, and the case history print manager is used to realize definition that case history is printed, and the cover of case history is beaten, complement and or continuous beating; Case history searching, managing device is provided, and case history searching, managing device is used for the typing key word, according to key word case history is retrieved; The quality of case history watch-dog is provided, and the quality of case history watch-dog is used to formulate the quality control rule of case history, according to the behavior of regular supervisory user and remind, and the operation of specification violation is write down and statistical study; The case history safety management is provided, and the case history safety management is used to realize that the vestige of case history keeps and digital signature.
In an embodiment of the present invention, also provide a kind of implement device of electronic health record, having comprised: the element module, be used to make up element, its form is a standard format, being used for typing can standardized diagnosis and treatment data; The chapters and sections module is used to make up chapters and sections, and its form is a free-format, is used for the diagnosis and treatment information of typing natural language form, and embeds element; And the case history module, being used to make up case history, it is made of chapters and sections, is used for the typing diagnosis and therapy recording.
Preferably, the element module comprises element stencil design device, is used to accept user's definition, to make up the format of element; The chapters and sections module comprises chapters and sections stencil design device, is used to accept user's definition, to make up the new chapters and sections template of chapters and sections; The case history module comprises case history stencil design device, is used to accept user's definition, to make up the new case history template of case history.
Preferably, the case history module also comprise following one of at least: template manager, be used for and will summarize by the natural language of user's typing and conclude, adopt the medical treatment and the diagnosis term of standard, be made into general and case history template each training disease that calls for specialized treatment special use; The medical record writing device is used to accept the modification that the user carries out case history; The case history print manager is used to realize definition that case history is printed, and the cover of case history is beaten, complement and or continuous beating; Case history searching, managing device is used for the typing key word, according to key word case history is retrieved; The quality of case history watch-dog is used to formulate the quality control rule of case history, according to the behavior of regular supervisory user and remind, and the operation of specification violation is write down and statistical study; The case history security manager is used to realize that the vestige of case history keeps and digital signature.
Preferably, also comprise: database module is used for preserving and management element, template and case history.
The electronic health record implementation method and the device of the above embodiment of the present invention, construct electronic health record because adopt the three-decker of element, chapters and sections, case history, can't satisfy the fixed problem that requires with dirigibility simultaneously so overcome the electronic health record of prior art, thereby realized the fusion of electronic health record nature text and structured text, can satisfy fixed simultaneously and requirement dirigibility.
Description of drawings
Accompanying drawing described herein is used to provide further understanding of the present invention, constitutes the application's a part, and illustrative examples of the present invention and explanation thereof are used to explain the present invention, do not constitute improper qualification of the present invention.In the accompanying drawings:
Fig. 1 shows the process flow diagram according to the implementation method of the electronic health record of the embodiment of the invention;
Fig. 2 shows according to the resulting electronic health record structural representation of the electronic health record implementation method of the embodiment of the invention;
Fig. 3 shows the block scheme according to the implement device of the electronic health record of the embodiment of the invention.
Embodiment
Below with reference to the accompanying drawings and in conjunction with the embodiments, describe the present invention in detail.
Fig. 1 shows the process flow diagram according to the implementation method of the electronic health record of the embodiment of the invention, may further comprise the steps:
Step S10 makes up element, and its form is a standard format, and being used for typing can standardized diagnosis and treatment data;
Step S20 makes up chapters and sections, and its form is a free-format, is used for the diagnosis and treatment information of typing natural language form, and embeds element; And
Step S30 makes up case history, and it is made of chapters and sections, is used for the typing diagnosis and therapy recording.
This electronic health record implementation method is because adopt the three-decker of element, chapters and sections, case history to construct electronic health record, can't satisfy the fixed problem that requires with dirigibility simultaneously so overcome the electronic health record of prior art, thereby realized the fusion of electronic health record nature text and structured text, can satisfy fixed simultaneously and requirement dirigibility.
Preferably, the form of element comprises: show attribute, be used for the exhibition method of indicator element, title, and the relation between other elements; And data attribute, be used for the designation data source.
Preferably, also comprise: element stencil design device is provided, is used to accept user's definition, to make up the format of element.
Preferably, can standardized diagnosis and treatment data comprise following at least one: the character of the symptom of patient name, sex, age, height, body weight, morbidity, site of pathological change, disease time, disease symptom, health check-up index.
Preferably, also comprise: make up the chapters and sections template of chapters and sections in advance, wherein, various chapters and sections templates embed different elements according to different types of diagnosis and treatment behavior.
Preferably, also comprise: chapters and sections stencil design device is provided, is used to accept user's definition, to make up the new chapters and sections template of chapters and sections.
Preferably, also comprise: make up the case history template of case history in advance, wherein, various case history templates are made of different chapters and sections according to dissimilar diagnosis and therapy recordings.
Preferably, also comprise: case history stencil design device is provided, is used to accept user's definition, to make up the new case history template of case history.
Preferably, step S30 also comprises: template manager is provided, and template manager is used for and will is summarized by the natural language of user's typing and conclude, and adopts the medical treatment and the diagnosis term of standard, is made into general and case history template each training disease that calls for specialized treatment special use; The medical record writing device is provided, and the medical record writing device is used to accept the modification that the user carries out case history; The case history print manager is provided, and the case history print manager is used to realize definition that case history is printed, and the cover of case history is beaten, complement and or continuous beating; Case history searching, managing device is provided, and case history searching, managing device is used for the typing key word, according to key word case history is retrieved; The quality of case history watch-dog is provided, and the quality of case history watch-dog is used to formulate the quality control rule of case history, according to the behavior of regular supervisory user and remind, and the operation of specification violation is write down and statistical study; The case history safety management is provided, and the case history safety management is used to realize that the vestige of case history keeps and digital signature.
The form case history is the structurized blank of case history, and it has extracted the project that case history must write down, and with the formal Specification of Dan Xuan, multiselect the form of recorded content.Its defective is that the project of text description can not its content of standard, no matter whether conditions of patients needs, the form case history all must be enumerated out all items and content, and it has limited doctor's thinking to a certain extent.
Free text and semi-structured case history are used for strict clinical research data management and statistics certain difficulty, and strict form case history is also having a lot of problems aspect the clinical descriptive power.Because often need to write case history again by hand in the reality use, it suffers clinician's opposition.Therefore, find that can to take into account the clinical and method scientific research demand very important.
The papery case history is the written record of doctor's natural language, and to the similar patient of the state of an illness, different doctors can write out diverse case history.
Stencil design device in the above preferred embodiment can be accepted the self-defined of user, has remedied the above-mentioned defective of form case history, free text and semi-structured case history, papery case history.
The electronic health record that obtains by the foregoing description, " dynamic, structured " is the characteristics of its highly significant, be to require as much as possible the knowledge point to be extract in case history according to medical speciality, and use medical science standard works and diagnosis technical term to write, make medical record writing can reach the standardization and the standardization of medical requirement.Structurized electronic health record has not only promoted the medical record writing quality, and the function that provides the papery case history to realize in follow-up developments: the retrieval of case history, analysis and quality monitoring or the like.A handling problem that importance is training, form or structured patient record of electronic health record research.Along with case history content coverage rate is more and more wider, structurized content can get more and more, and the structuring degree can continuous refinement.The design of electronic medical record system must be considered this demand for development, can at any time emerging structured content be integrated into case history.
The real intelligentized electronic health record that is obtained by the foregoing description can extract required knowledge point of medical science and logical relation thereof automatically from free text, remind the doctor not omit the content that must write down.
Preferably, also comprise: make up database, be used for preserving and management element, template and case history.Thus obtained database can be called knowledge base.
The content of case history shows standardization at allogenic disease, and each case has uniqueness again simultaneously, so writing of case history again must satisfying personalized requirement on standardized basis.Simple standardization has limited doctor's thinking, is unfavorable for the development of medical science, only takes into account standardization and personalization, could guarantee the practicality of case history and expansionary.And the case history method for designing adopts full fixed sturcture pattern can't handle standardization and personalized contradiction well substantially at present.
Therefore the electronic health record content should be structuring or semi-structured description and storage.For content, support semi-structured mode to extract the framework of content based on descriptive content.Structuring is not only used in editing process, still can keep these structures so that later use when preserving.Doctor's medical record writing must be to express by relatively more clear and more coherent natural language, the key element and the data that in the middle of these natural languages, contain the medical science diagnosis and treatment simultaneously, for collection and the utilization that guarantees these crucial medical datas, just must carry out Structured Design to these critical datas, could well carry out the standardization editor, storage and extraction.Simultaneously in case history except these critical datas, need not structurized natural language in addition in a large number, when carrying out electronic health record editor and storage, just must realize that the nature text merges mutually with structured text, and the electronic health record implementation method of above preferred embodiment has realized the two suitable fusion.
Fig. 2 shows the resulting electronic health record structural representation according to the embodiment of the invention.This electronic health record implementation method is on the basis of the present situation of electronic health record application at present, in conjunction with labor to each training case history, design a kind of dynamic, structured electronic health record model, thereby with the brand-new electronic health record of this model development, realized the fixed and dirigibility of electronic health record, nature text and structured text, standardization and personalized reasonable fusion, thereby the practicality of assurance electronic health record and expansionary.
According to the analysis to the case history structure, the design is divided into three levels with the structure of case history: element, chapters and sections, case history.A plurality of elements and natural language constitute chapters and sections, and a plurality of chapters and sections constitute a case history, and many parts of dissimilar case histories have just constituted complete electronic health record of diagnosis and treatment of patient, support writing of whole case history by knowledge base simultaneously and constitute.
(1) element
Element is the minimal parts that constitutes electronic health record, it is the diagnosis and treatment data of the key that contains in the case history, the character of the symptom of its sign patient name, sex, age, height, body weight, morbidity, site of pathological change, disease time, disease symptom, health check-up index or the like, it can freely be defined in the case history by the user and reuse.Attribute of an element comprises shows attribute and data attribute, show that attribute comprises the exhibition method of element, title, and relation between other elements or the like, data attribute mainly refers to the element data source, Data Source can be the data from other system, the knowledge base that also can come the self-supporting element content.
(2) chapters and sections
The chapters and sections of case history are meant a specific paragraph of describing patient's diagnosis and treatment information, and it is that a plurality of elements and natural language combine, and chapters and sections also can be reused in case history by User Defined.According to various disease the content of chapters and sections is come out promptly to become the template of chapters and sections with the formal representation of element and natural language, just become the knowledge base of supporting the chapters and sections content.
(3) case history
Case history is divided variety classes, comprises the record of being admitted to hospital, course of disease record first, and big case history, progress note, the record or the like of leaving hospital, dissimilar case histories is to be combined by different chapters and sections.Each chapter content of case history can be set in advance out the template that promptly becomes case history according to various disease, just become the knowledge base of supporting the case history content.
(4) knowledge base
The knowledge base basis of case history is to the preset data of the support case history content of the experience formation of certain disease treatment.At electronic health record element, chapters and sections, three different levels of case history, knowledge base also is divided into different levels.Knowledge base at element is the data content default according to various disease to each element, and it can be with reference to international medical terminology standard SNOMED; At the knowledge base of chapters and sections is that experience accumulation according to various disease utilizes element and natural language to form the template that relatively-stationary written contents is chapters and sections.At the knowledge base of case history is that experience accumulation according to various disease forms the template that relatively-stationary written contents is a case history to case history.Knowledge base can realize with various databases commonly used, to realize storage and the management to element, chapters and sections, case history.
Be divided into element, chapters and sections, three levels of case history by structure with electronic health record, content at all levels can define flexibly simultaneously, syntagmatic each other can define flexibly, this has just guaranteed the dirigibility of case history, and the element, chapters and sections, the case history that constitute electronic health record are the structures of the good relative standard of predefined, thereby have also guaranteed the standardization and the standardization of electronic health record.
Illustrate the project organization of electronic health record below.
The design of electronic health record structured storage
(1) case history structured storage signal
(2) XML document presentation mode
XML (extend markup language) is a kind of structure description language.It is not only a kind of identifiable language, a kind of especially meta-language that can define the description object structure.The self-contained structure of XML document makes the information that exchanges between system " understanding " mutually, and for the ease of the storage and the displaying of electronic health record, also for the ease of the extraction and the utilization of medical record data, so the design adopts the XML language to describe dynamic, structured case history.
<？xml?version＝“1.0″encoding＝“gb2312″？>
＜RAN 〉
＜main suit 〉
......
＜/main suit 〉
＜present illness history 〉
Before＜disease time＞20 day＜/disease time 〉
＜onset situation〉tired back＜/the onset situation 〉
＜symptom title〉pain＜/the symptom title 〉
＜symptom position〉pareordia＜/the symptom position 〉
......
＜/present illness history 〉
＜/RAN＞
Fig. 3 shows the block scheme according to the implement device of the electronic health record of the embodiment of the invention, comprising:
Chapters and sections module 20 is used to make up chapters and sections, and its form is a free-format, is used for the diagnosis and treatment information of typing natural language form, and embeds element; And
This electronic health record implement device is because adopt the three-decker of element, chapters and sections, case history to construct electronic health record, can't satisfy the fixed problem that requires with dirigibility simultaneously so overcome the electronic health record of prior art, thereby realized the fusion of electronic health record nature text and structured text, can satisfy fixed simultaneously and requirement dirigibility.
Preferably, the element module comprises element stencil design device, is used to accept user's definition, to make up the format of element; The chapters and sections module comprises chapters and sections stencil design device, is used to accept user's definition, to make up the new chapters and sections template of chapters and sections; The case history module comprises case history stencil design device, is used to accept user's definition, to make up the new case history template of case history.
Preferably, the case history module also comprise following one of at least:
1) case history designer
Design and making case history template are that natural language in the case history is refined and concludes, this electronic medical record system provides a case history stencil design platform, the medical worker can freely define element, chapters and sections, case history, contents such as each knowledge base, after the function of having understood multiple controls such as the multiselect that computer program provides, Dan Xuan, drop-down option, single file text, multiline text, label, form, medical knowledge base in conjunction with the program binding, need not peopleware's programming, just can do it yourself design and making case history template.Various controls are carried out organic rational combination just finished and a can describe patient's symptom and language standard, abundant in content full and accurate case history, already used case history template can be revised at any time simultaneously.Kind, position and the input content of case history stencil design platform except designing control can also design the logical relation between each control, tree promptly above-mentioned.
2) template manager
The case history template is exactly following assisting of computer software, the natural language that the doctor is write is summarized and is concluded, and adopts the medical treatment and the diagnosis term of standard, is made into general and case history template each training disease that calls for specialized treatment special use, both make things convenient for the doctor to import, realized the structurized purpose of case history again.
Template manager can define the particular content of certain chapters and sections according to disease, or defines the particular content of whole case history, and these contents are made of jointly natural language and element, can directly use when medical record writing, improves medical record writing efficient and quality.
3) medical record writing device
The medical record writing device is that case history is increased, the instrument of revising, natural language wherein can freely be edited, the element project is with drop-down selection standard works, when editor, dynamically increase element or chapters and sections, can design the logical relation between projects, according to the logical relation and the state of an illness, show the project that to fill in or the like neatly, its great advantage is that the case history template is separated with the storage of case history, really realize dynamic case history template, made the application person of electronic health record can constantly revise and improve the case history template easily.
4) knowledge base management device
Knowledge base is increased, and deletion is with modification.
5) case history print manager
The definition that realization is printed case history, the cover of case history is beaten, complement, continuous beat etc.
6) case history searching, managing device
According to various key words case history is retrieved.
7) quality of case history watch-dog
Formulate the quality of case history control law, according to rule monitoring doctor's behavior and remind, and the operation of specification violation is write down and statistical study.
8) electronic health record security manager
The vestige that mainly comprises electronic medical record system keeps and digital signature.
Doctor's medical record writing has the format needs of fixing standard, simultaneously content written is also had relatively more fixing integrality requirement, and this just requires the design energy standard doctor's of electronic health record medical record writing behavior, and the project that must import is reminded and early warning.But medical science is a kind of theory and experience subject combining, each doctor of while, each patient has the demand of a lot of personalizations, therefore not only the design that requires electronic health record is being satisfied on the basis of standardization simultaneously but also must satisfied the requirement that the doctor handles flexibly, traditional electronic health record processing mode or standard but dumb very, perhaps very flexible but lack of standardization, can't solve the fixed contradiction with the dirigibility requirement of electronic health record.The electronic health record implement device of above preferred embodiment has been realized the two suitable fusion.
From above description, as can be seen, the electronic health record implementation method and the device of the above embodiments of the present invention are because adopt the three-decker of element, chapters and sections, case history to construct electronic health record, so solved the contradiction of fixed gange plasticity demand and dirigibility demand in the case history electronization process; Solved the problem that natural language and structured language merge mutually in the electronic health record processing procedure; Solved medically contradiction to case history standardization and personal needs.Realized:
1. the logical model of dynamic, structured electronic health record;
2. the storage format of dynamic, structured electronic health record;
3. the function of dynamic, structured electronic health record design.
Obviously, those skilled in the art should be understood that, above-mentioned each module of the present invention or each step can realize with the general calculation device, they can concentrate on the single calculation element, perhaps be distributed on the network that a plurality of calculation element forms, alternatively, they can be realized with the executable program code of calculation element, thereby, they can be stored in the memory storage and carry out by calculation element, perhaps they are made into each integrated circuit modules respectively, perhaps a plurality of modules in them or step are made into the single integrated circuit module and realize.Like this, the present invention is not restricted to any specific hardware and software combination.
The above is the preferred embodiments of the present invention only, is not limited to the present invention, and for a person skilled in the art, the present invention can have various changes and variation.Within the spirit and principles in the present invention all, any modification of being done, be equal to replacement, improvement etc., all should be included within protection scope of the present invention.
Claims (14)
1. the implementation method of an electronic health record is characterized in that, may further comprise the steps:
Make up element, its form is a standard format, and being used for typing can standardized diagnosis and treatment data;
Make up chapters and sections, its form is a free-format, is used for the diagnosis and treatment information of typing natural language form, and embeds described element; And
Make up case history, it is made of described chapters and sections, is used for the typing diagnosis and therapy recording.
2. implementation method according to claim 1 is characterized in that, the form of described element comprises:
Show attribute, be used to indicate the exhibition method of described element, title, and the relation between other elements; And
Data attribute is used for the designation data source.
3. implementation method according to claim 2 is characterized in that, also comprises:
Element stencil design device is provided, is used to accept user's definition, to make up the format of described element.
4. implementation method according to claim 1 is characterized in that, describedly can standardized diagnosis and treatment data comprise following at least one:
The character of the symptom of patient name, sex, age, height, body weight, morbidity, site of pathological change, disease time, disease symptom, health check-up index.
5. implementation method according to claim 1 is characterized in that, also comprises:
Make up the chapters and sections template of described chapters and sections in advance, wherein, various described chapters and sections templates embed different described elements according to different types of diagnosis and treatment behavior.
6. implementation method according to claim 5 is characterized in that, also comprises:
Chapters and sections stencil design device is provided, is used to accept user's definition, to make up the new chapters and sections template of described chapters and sections.
7. implementation method according to claim 1 is characterized in that, also comprises:
Make up the case history template of described case history in advance, wherein, various described case history templates are made of different described chapters and sections according to dissimilar diagnosis and therapy recordings.
8. implementation method according to claim 7 is characterized in that, also comprises:
Case history stencil design device is provided, is used to accept user's definition, to make up the new case history template of described case history.
9. implementation method according to claim 1 is characterized in that, also comprises:
Make up database, be used for preserving and managing described element, template and case history.
10. implementation method according to claim 1 is characterized in that, makes up case history and also comprises:
Template manager is provided, and described template manager is used for and will is summarized by the natural language of user's typing and conclude, and adopts the medical treatment and the diagnosis term of standard, is made into general and case history template each training disease that calls for specialized treatment special use;
The medical record writing device is provided, and described medical record writing device is used to accept the modification that the user carries out described case history;
The case history print manager is provided, and described case history print manager is used to realize definition that described case history is printed, and the cover of case history is beaten, complement and or continuous beating;
Case history searching, managing device is provided, and described case history searching, managing device is used for the typing key word, according to described key word described case history is retrieved;
The quality of case history watch-dog is provided, and described quality of case history watch-dog is used to formulate the quality control rule of described case history, according to the behavior of described regular supervisory user and remind, and the operation of specification violation is write down and statistical study;
The case history safety management is provided, and described case history safety management is used to realize that the vestige of described case history keeps and digital signature.
11. the implement device of an electronic health record is characterized in that, comprising:
The element module is used to make up element, and its form is a standard format, and being used for typing can standardized diagnosis and treatment data;
The chapters and sections module is used to make up chapters and sections, and its form is a free-format, is used for the diagnosis and treatment information of typing natural language form, and embeds described element; And
The case history module is used to make up case history, and it is made of described chapters and sections, is used for the typing diagnosis and therapy recording.
12. implement device according to claim 11 is characterized in that,
Described element module comprises element stencil design device, is used to accept user's definition, to make up the format of described element;
Described chapters and sections module comprises chapters and sections stencil design device, is used to accept user's definition, to make up the new chapters and sections template of described chapters and sections;
Described case history module comprises case history stencil design device, is used to accept user's definition, to make up the new case history template of described case history.
13. implement device according to claim 11 is characterized in that, described case history module also comprise following one of at least:
Template manager is used for and will is summarized by the natural language of user's typing and conclude, and adopts the medical treatment and the diagnosis term of standard, is made into general and case history template each training disease that calls for specialized treatment special use;
The medical record writing device is used to accept the modification that the user carries out described case history;
The case history print manager is used to realize definition that described case history is printed, and the cover of case history is beaten, complement and or continuous beating;
Case history searching, managing device is used for the typing key word, according to described key word described case history is retrieved;
The quality of case history watch-dog is used to formulate the quality control rule of described case history, according to the behavior of described regular supervisory user and remind, and the operation of specification violation is write down and statistical study;
The case history security manager is used to realize that the vestige of described case history keeps and digital signature.
14. implement device according to claim 11 is characterized in that, also comprises:
Database module is used for preserving and managing described element, template and case history.
Priority Applications (1)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CNA200810007256XA CN101236579A (en) | 2008-02-20 | 2008-02-20 | Dynamic structured electronic patient history |
Applications Claiming Priority (1)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CNA200810007256XA CN101236579A (en) | 2008-02-20 | 2008-02-20 | Dynamic structured electronic patient history |
Publications (1)
| Publication Number | Publication Date |
|---|---|
| CN101236579A true CN101236579A (en) | 2008-08-06 |
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| CNA200810007256XA Pending CN101236579A (en) | 2008-02-20 | 2008-02-20 | Dynamic structured electronic patient history |
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| CN103778311A (en) * | 2012-10-19 | 2014-05-07 | 杭州美诺泰科科技有限公司 | Entry terminal and method for first-aid workstation structured electronic medical records |
| CN104050393A (en) * | 2014-07-10 | 2014-09-17 | 首都医科大学附属北京佑安医院 | Progress note self-inspection system and method |
| CN104050615A (en) * | 2014-07-10 | 2014-09-17 | 首都医科大学附属北京佑安医院 | System for generating structured electronic medical record |
| CN104835092A (en) * | 2014-02-11 | 2015-08-12 | 蓝网科技有限公司 | Method for automatically generating electronic medical record contents according to patient's sex |
| CN105160615A (en) * | 2015-09-08 | 2015-12-16 | 浙江浙大中控信息技术有限公司 | Free retrieval case search engine system and searching method |
| CN105550524A (en) * | 2013-07-17 | 2016-05-04 | 中国中医科学院 | Novel clinical case data collection system and collection method |
| CN105808951A (en) * | 2016-03-10 | 2016-07-27 | 宁波金唐软件有限公司 | Quality control method and apparatus for electronic medical record |
| CN106202027A (en) * | 2016-08-12 | 2016-12-07 | 南京都昌信息科技有限公司 | A kind of Tibetan language electronic medical record system text editor |
| CN106815256A (en) * | 2015-12-01 | 2017-06-09 | 北京国双科技有限公司 | Set up the method and device of laws and regulations bar fund incidence relation |
| CN107545929A (en) * | 2016-06-28 | 2018-01-05 | 学透通医疗科技（上海）有限公司 | A kind of Templated patient in hospital hemodialysis information recording method |
| CN107563127A (en) * | 2017-10-27 | 2018-01-09 | 张川海 | The rapid generation and system of a kind of electronic health record |
| CN107908768A (en) * | 2017-09-30 | 2018-04-13 | 北京颐圣智能科技有限公司 | Method, apparatus, computer equipment and the storage medium of electronic health record processing |
| CN108461110A (en) * | 2017-02-21 | 2018-08-28 | 阿里巴巴集团控股有限公司 | Medical information processing method, device and equipment |
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| CN101908093A (en) * | 2010-01-25 | 2010-12-08 | 田小平 | Electronic medical record and method and system for controlling medical process on the basis of same |
| CN101944162A (en) * | 2010-09-02 | 2011-01-12 | 江苏大学 | Electronic medical record template system based on XML file and manufacturing method of electronic medical record template |
| CN102819656A (en) * | 2011-06-10 | 2012-12-12 | 中国科学院深圳先进技术研究院 | System and method for generating electronic medical record |
| CN102819656B (en) * | 2011-06-10 | 2016-02-24 | 中国科学院深圳先进技术研究院 | Generate the system and method for electronic health record |
| CN102346814A (en) * | 2011-11-03 | 2012-02-08 | 厦门市智业软件工程有限公司 | Entering method of tabular fragment structured EMR (Electronic Medical Record) |
| CN102542158A (en) * | 2011-12-07 | 2012-07-04 | 南京毗邻医疗科技有限公司 | Intelligent medical service system based on composite diagnosis and treatment template and composite illness condition template |
| CN102799787A (en) * | 2012-07-25 | 2012-11-28 | 中国康复研究中心 | Dynamic monitoring and data analysis system for patients suffering from spinal cord injury |
| CN103778311A (en) * | 2012-10-19 | 2014-05-07 | 杭州美诺泰科科技有限公司 | Entry terminal and method for first-aid workstation structured electronic medical records |
| CN103144456A (en) * | 2013-03-21 | 2013-06-12 | 无锡曼荼罗软件有限公司 | Method and system for printing repeatedly and continuously on same piece of paper |
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| CN105550524B (en) * | 2013-07-17 | 2018-02-13 | 中国中医科学院 | A kind of clinical case data collecting system and acquisition method |
| CN105550524A (en) * | 2013-07-17 | 2016-05-04 | 中国中医科学院 | Novel clinical case data collection system and collection method |
| CN103473444A (en) * | 2013-08-27 | 2013-12-25 | 温州医科大学附属第一医院 | Electronic medical record system based on intelligent analyzing data structure and processing method of system |
| CN103530358A (en) * | 2013-10-10 | 2014-01-22 | 中国中医科学院 | Electronic medical record rapid recording system based on incremental type term bank |
| CN103559674A (en) * | 2013-11-25 | 2014-02-05 | 方正国际软件有限公司 | Structured entry device and method of medical record document |
| CN103578074A (en) * | 2013-11-25 | 2014-02-12 | 方正国际软件有限公司 | Input assisting system and input assisting method for medical history |
| CN104835092A (en) * | 2014-02-11 | 2015-08-12 | 蓝网科技有限公司 | Method for automatically generating electronic medical record contents according to patient's sex |
| CN104050615A (en) * | 2014-07-10 | 2014-09-17 | 首都医科大学附属北京佑安医院 | System for generating structured electronic medical record |
| CN104050393A (en) * | 2014-07-10 | 2014-09-17 | 首都医科大学附属北京佑安医院 | Progress note self-inspection system and method |
| CN105160615A (en) * | 2015-09-08 | 2015-12-16 | 浙江浙大中控信息技术有限公司 | Free retrieval case search engine system and searching method |
| CN106815256A (en) * | 2015-12-01 | 2017-06-09 | 北京国双科技有限公司 | Set up the method and device of laws and regulations bar fund incidence relation |
| CN105808951A (en) * | 2016-03-10 | 2016-07-27 | 宁波金唐软件有限公司 | Quality control method and apparatus for electronic medical record |
| CN107545929A (en) * | 2016-06-28 | 2018-01-05 | 学透通医疗科技（上海）有限公司 | A kind of Templated patient in hospital hemodialysis information recording method |
| CN106202027A (en) * | 2016-08-12 | 2016-12-07 | 南京都昌信息科技有限公司 | A kind of Tibetan language electronic medical record system text editor |
| CN108461110B (en) * | 2017-02-21 | 2021-07-23 | 阿里巴巴集团控股有限公司 | Medical information processing method, device and equipment |
| CN108461110A (en) * | 2017-02-21 | 2018-08-28 | 阿里巴巴集团控股有限公司 | Medical information processing method, device and equipment |
| CN107908768A (en) * | 2017-09-30 | 2018-04-13 | 北京颐圣智能科技有限公司 | Method, apparatus, computer equipment and the storage medium of electronic health record processing |
| CN107563127A (en) * | 2017-10-27 | 2018-01-09 | 张川海 | The rapid generation and system of a kind of electronic health record |
| CN109408635A (en) * | 2018-09-28 | 2019-03-01 | 湖南智腾安控科技有限公司 | A kind of case history document standard processing system and method |
| CN110070925A (en) * | 2019-03-11 | 2019-07-30 | 张宏家 | A kind of generation method of electronic health record, device and electronic equipment |
| CN110600095A (en) * | 2019-08-23 | 2019-12-20 | 和宇健康科技股份有限公司 | Quality control method and system for electronic medical record |
| CN110718278A (en) * | 2019-09-04 | 2020-01-21 | 杭州憶盛医疗科技有限公司 | High-end electronic medical record system for realizing intelligent medical treatment |
| CN111261251A (en) * | 2020-01-20 | 2020-06-09 | 北京百度网讯科技有限公司 | Method and device for generating electronic medical record, electronic equipment and computer-readable storage medium |
| CN111597789A (en) * | 2020-04-07 | 2020-08-28 | 华瑞新智科技（北京）有限公司 | Electronic medical record text evaluation method and equipment |
| CN111755091A (en) * | 2020-06-28 | 2020-10-09 | 北京嘉和海森健康科技有限公司 | Electronic medical record processing method and device |
| CN111755091B (en) * | 2020-06-28 | 2024-02-27 | 北京嘉和海森健康科技有限公司 | Electronic medical record processing method and device |
| CN111985197A (en) * | 2020-07-17 | 2020-11-24 | 北京欧应信息技术有限公司 | Template generation method based on medical information |
| CN112349367A (en) * | 2020-11-11 | 2021-02-09 | 北京嘉和海森健康科技有限公司 | Method and device for generating simulation medical record, electronic equipment and storage medium |
| CN112349367B (en) * | 2020-11-11 | 2023-08-08 | 北京嘉和海森健康科技有限公司 | Method, device, electronic equipment and storage medium for generating simulated medical record |
| CN112951354A (en) * | 2021-02-24 | 2021-06-11 | 南京得塔软件科技有限公司 | Intelligent configuration method suitable for electronic medical record structurization |
| CN113838546A (en) * | 2021-09-24 | 2021-12-24 | 山东众阳健康科技集团有限公司 | Medical record management method and system based on content quality control |
| CN116453640A (en) * | 2023-06-15 | 2023-07-18 | 北京四海汇智科技有限公司 | Method and device for constructing clinical special disease library based on multi-label screening and electronic equipment |
| CN116453640B (en) * | 2023-06-15 | 2023-09-22 | 北京四海汇智科技有限公司 | Method and device for constructing clinical special disease library based on multi-label screening and electronic equipment |
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