CN101582100A - Terminal medical record quality evaluation input system and input method thereof - Google Patents
Terminal medical record quality evaluation input system and input method thereof Download PDFInfo
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- CN101582100A CN101582100A CNA2008100162509A CN200810016250A CN101582100A CN 101582100 A CN101582100 A CN 101582100A CN A2008100162509 A CNA2008100162509 A CN A2008100162509A CN 200810016250 A CN200810016250 A CN 200810016250A CN 101582100 A CN101582100 A CN 101582100A
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Abstract
The invention relates to a terminal medical record quality evaluation input system and an input method thereof. The terminal medical record quality evaluation input system comprises a data server subsystem, an input service terminal and a data transmission subsystem, wherein the data server subsystem is a server group with storage function and is supported by a database which stores terminal medical record information and the basic information data of inpatients; the input service terminal is used as a service terminal, sets parameter codes for the fields of information needing input, such as disease diagnosis names, codes (1CD10) of the disease diagnosis names, operation names, medical record blank contents, writing doctors, superior doctors and inspectors, analyzes the parameter codes and returns the selected contents to the input service terminal; and the data transmission subsystem is used as a network transmission device, realizes data transmission and detection and extracts and inputs the terminal medical record information and the basic information data of the inpatients from the data server subsystem to the input service terminal so as to realize data interaction. The input method normalizes and standardizes the quality evaluation data of terminal medical records.
Description
Technical field
What the present invention relates to is a kind of terminal medical record quality evaluation input system, particularly be a kind of input method that utilizes parameter extraction normal dictionary data.
Background technology
Case history is accompanied by the generation of medical science and the development that produces, be accompanied by medical science develops.The human medical records of preserving the earliest is the 48 exception sections operation case history that Egyptian doctor Imhotep is approximately writing down 290 years Christian eras.In China, the preservation case history of scientific system only has the history in more than 80 year.Medical records is the objective basis that the medical worker diagnoses and differentiates disease of patient, also is to patient's treatment and lapses to and carry out the realistic of comprehensive system science and sum up, simultaneously the still valuable data of medical research aspect.So complete medical records is not only the requirement that solves medical tangle, also be to cultivate rigorous scientism and meticulous, the factualistic important content of medical worker.Enter 21 century, health ministry is paid attention to more to the medical record and the medical record management of whole nation hospitals at different levels, the annual quality of case history inspection of all organizing the whole province or the whole nation.The staff of basic hospital quality of case history control roller office, the management to terminal medical record in the past is: the selective examination terminal medical record, related content data etc. are carried out the Hand writing record, and artificial judgment medical record grade, filing is reprocessed or is preserved.But the record standard disunity of Hand writing, word is lack of standardization, and the paper record data lose easily, and it is short to preserve the time limit, can't be promptly and accurately provides reliable reference frame for hospital clinical and administrative department.
For overcoming above-mentioned defective, creator of the present invention is through studying and put into practice the realization that has obtained this creation finally for a long time.
Summary of the invention
The objective of the invention is to, a kind of terminal medical record quality evaluation input system and input method are provided, by parameter extraction normal dictionary data, and the data after will resolving are filled in into the terminal medical record quality evaluation system, automatically judge the medical record grade simultaneously, judge whether to be Class A operation case history, judge whether to be single sick kind expense control case history, guarantee the accuracy and the standardization of terminal medical record data, thereby for the medical research aspect provides valuable data, reduce medical tangle, provide reliable basis for medical administrative department carries out scientific management to hospital.
For achieving the above object, the technical solution used in the present invention is, a kind of terminal medical record quality evaluation input system at first is provided, and it comprises:
The data server subsystem, it is the server farm with memory function, described data server subsystem is subjected to database support, wherein stores terminal medical record information data and inpatient's essential information data;
The typing service terminal, it is a service terminal, gathers the inpatient's essential information data in the described data server subsystem, and is transported to described typing service terminal; For needing typing medical diagnosis on disease title and coding (ICD10), operation names, case history defective content, writing doctor, higher level doctor, supervisory personnel's field setup parameter coding, content after will selecting after parameter coding is resolved is returned, and realizes the typing of terminal medical record quality evaluation information;
The data transmission subsystem, it is a network transmission device, realizes data transmission and detection, extracts terminal medical record information and inpatient's essential information in the described data server subsystem, and is transported to described typing service terminal, realizes the mutual of data;
Preferable, described data server subsystem comprises the Intranet that the exclusive data server forms and is arranged on wherein physical isolation apparatus;
Preferable, described exclusive data server adopts Dual-Computer Hot-Standby System, tape library data backup device;
Preferable, described data transmission subsystem comprises two kinds of service channels of LAN (Local Area Network) and internet;
Next the invention provides a kind of terminal medical record quality evaluation input method, and it is to realize that by above-mentioned terminal medical record quality evaluation input system it is characterized in that: it step that comprises has:
Step a: set up the database that stores terminal medical record information and inpatient's essential information data;
Step b: set up the ICD10 normal dictionary, set up Class A operation normal dictionary, set up the normal dictionary of single sick kind expense control, set up personnel's dictionary, set up quality of case history and estimate defective content and standard of deducting point normal dictionary;
Step c: land the typing service terminal, and get in touch with the foundation of data server subsystem;
Steps d: extract the Database Systems date automatically for date field; Automatically gather for medical record number and patient's name's data information system; For needing typing medical diagnosis on disease title and coding (ICD10), operation names, case history defective content, writing doctor, higher level doctor, supervisory personnel's field setup parameter coding;
Step e: extract and the analytic parameter coding, if parameter coding resolve successfully, execution in step f then, otherwise, execution in step h;
Step f: call corresponding database automatically according to resolving back parameter coding content, and according to the parameter coding content after resolving according to phonetic sign indicating number or constructive code retrieval, and the content after will selecting according to the parameter coding content after resolving is returned and is presented at automatically on the typing field;
Step g: according to the case history defective content of typing, according to the standard of deducting point of default, system judges the medical record grade automatically, and is presented on the medical record rank field; According to the operation names of typing, according to the Class A operation dictionary of default, system judges whether to be the Class A operation automatically; According to the medical diagnosis on disease title and the coding (ICD10) of typing, system judges whether to be single sick kind expense control case history automatically;
Step h: obtain the error message prompting;
Step I: typing is finished.
Preferable, described terminal medical record quality evaluation data message comprises: medical record number, patient's name, write doctor, higher level doctor, medical record grade, medical diagnosis on disease title and coding (ICD10), operation names, supervisory personnel, check data, case history defective content, standard of deducting point.
Preferable, described parameter coding comprises: call data dictionary title, search criteria coding, return code field.
The invention has the advantages that:
1, input system can improve quality of case history control personnel's work efficiency fast and easily, makes scoring standardization, the rationalization of terminal medical record;
2, complete preservation the data behind the terminal medical record quality evaluation, promoted the leading position that relevant medical worker handles in medical tangle, malpractice;
3, standard medical worker medical record writing standard reduces medical tangle, cultivates the scientism that the medical worker forbids;
4, for carrying out scientific management to hospital, medical administrative department provides reliable basis and decision references;
Description of drawings:
Fig. 1 is the structure diagram of terminal medical record quality evaluation input system of the present invention;
Fig. 2 is the process flow diagram of terminal medical record quality evaluation input method of the present invention;
Embodiment
Below in conjunction with accompanying drawing, be described in more detail with other technical characterictic and advantage the present invention is above-mentioned.
Consult shown in Figure 1, it is for the structure diagram of terminal medical record quality evaluation input system of the present invention, comprise: the data server subsystem, it is the server farm with memory function, described data server subsystem is subjected to database support, wherein stores terminal medical record information data and inpatient's essential information data; Described data server subsystem is erected at the information for hospital center, adopts Dual-Computer Hot-Standby System and tape library data backup device; Described data server subsystem comprises the Intranet that the exclusive data server forms and is arranged on wherein physical isolation apparatus.
The typing service terminal, it is a service terminal, realizes the typing of terminal medical record data message, and gathers the inpatient's essential information data in the described data server subsystem, and is transported to described typing service terminal.The staff of quality of case history control center of hospital carries out terminal medical record quality evaluation typing operation;
The data transmission subsystem, it is a network transmission device, realizes data transmission and detection, extracts terminal medical record information and inpatient's essential information in the described data server subsystem, and is transported to described typing service terminal, realizes the mutual of data.Described data transmission subsystem comprises two kinds of network service channels of LAN (Local Area Network) and internet.
The security strategy that database server subsystem of the present invention adopts comprises: Dual-Computer Hot-Standby System and tape library data backup device, wherein complete backup mode is adopted in the tape library data backup.Below introduce the characteristics of these two kinds of strategies in detail:
1. Dual-Computer Hot-Standby System
So-called two-node cluster hot backup be exactly a main frame be working machine, another main frame is a backup machine.Under system's normal condition, working machine is that infosystem provides support, (working machine monitors simultaneously also whether backup machine is normal to the ruuning situation of backup machine follow-up work machine, sometimes backup machine occurs unusual because of certain reason, working machine reporting system keeper as early as possible solves, and guarantees the reliability of next time switching).When working machine occur unusual, can not the support information system during operation, backup machine is initiatively taken over the work of working machine, continue to support the operation of data message, thereby the guarantee information system can continually move.The working machine of delaying is through after repairing normally, and the system manager is by administration order or via in artificial or automatic mode working machine being switched back in the work of backup machine; Also can activate supervisory programme, monitor the ruuning situation of backup machine, at this moment, backup machine has originally just become working machine, and original working machine has just become backup machine.
2. backup fully
All back up fully system every day, comprises system architecture, view, storing process and data.The benefit of this backup is intuitively, easily understands.When loss of data, only need the complete backup file of data just data can be recovered fully, we adopt and back up fully every day 2 times, and system is automatically at the set time automated back-up, and with strategy that last time, this time period backed up data covered.
Consult shown in Figure 2ly, it may further comprise the steps for the process flow diagram of terminal medical record quality evaluation input method of the present invention:
Step a: set up the database that stores terminal medical record information and inpatient's essential information data;
Step b: set up the ICD10 normal dictionary, set up Class A operation normal dictionary, set up the normal dictionary of single sick kind expense control, set up personnel's dictionary, set up quality of case history and estimate defective content and standard of deducting point normal dictionary;
Step c: land the typing service terminal, and get in touch with the foundation of data server subsystem;
Steps d: extract the Database Systems date automatically for date field; Automatically gather for medical record number and patient's name's data information system; For needing typing medical diagnosis on disease title and coding (ICD10), operation names, case history defective content, writing doctor, higher level doctor, supervisory personnel's field setup parameter coding;
Step e: extract and the analytic parameter coding, if parameter coding resolve successfully, execution in step f then, otherwise, execution in step h;
Step f: call corresponding database automatically according to resolving back parameter coding content, and according to the parameter coding content after resolving according to phonetic sign indicating number or constructive code retrieval, and the content after will selecting according to the parameter coding content after resolving is returned and is presented at automatically on the typing field;
Step g: according to the case history defective content of typing, according to the standard of deducting point of default, system judges the medical record grade automatically, and is presented on the medical record rank field; According to the operation names of typing, according to the Class A operation dictionary of default, system judges whether to be the Class A operation automatically; According to the medical diagnosis on disease title and the coding (ICD10) of typing, system judges whether to be single sick kind expense control case history automatically;
Step h: obtain the error message prompting;
Step I: typing is finished.
Described terminal medical record quality evaluation data message comprises: medical record number, patient's name, write doctor, higher level doctor, medical record grade, medical diagnosis on disease title and coding (ICD10), operation names, supervisory personnel, check data, case history defective content, standard of deducting point.
Described parameter coding comprises: call data dictionary title, search criteria coding, return code field.
For example: at medical diagnosis on disease title and code field parameter coding is set and is " ICD10; PYM; ZDMC ", wherein international disease classification standard coding ICD10 normal dictionary is called in " ICD10 " expression, phonetic sign indicating number (PYM) retrieve data is adopted in " PYM " expression, after " ZDMC " represented that search complete, data were returned diagnosis name (ZDMC) field contents in the international disease classification standard coding ICD10 normal dictionary.
The present invention is that collection computer generalization is used network, the comprehensive medical record quality evaluation input system of medical record Quality Control Technology and one.
Terminal medical record quality evaluation input system standard of the present invention medical worker's medical record writing standard, reduce medical tangle, play an important role to cultivating the scientism that the medical worker forbids; The preservation that terminal medical record quality evaluation input system of the present invention is complete data behind the terminal medical record quality evaluation, promoted the leading position that the medical worker handles in medical tangle, malpractice; Terminal medical record quality evaluation input system of the present invention provides reliable basis and decision references by evaluation, statistics, analysis to the medical record quality for medical administrative department carries out scientific management to hospital.
More than under only be preferred embodiment of the present invention, only be illustrative for the purpose of the present invention, but not restricted type.Those skilled in the art is understood, and can carry out many changes, modification even equivalence to it in the spirit and scope that claim of the present invention limits, but all will fall within the scope of protection of the present invention.
Claims (7)
1, a kind of terminal medical record quality evaluation input system, it is characterized in that: it comprises:
The data server subsystem, it is the server farm with memory function, described data server subsystem is subjected to database support, wherein stores terminal medical record information data and inpatient's essential information data;
The typing service terminal, it is a service terminal, gathers the inpatient's essential information data in the described data server subsystem, and is transported to described typing service terminal; For needing typing medical diagnosis on disease icd10 sign indicating number, Class A operation dictionary, single sick kind expense control, case history defective content, writing doctor, higher level doctor, supervisory personnel's field setup parameter coding, content after will selecting after parameter coding is resolved is returned, and realizes the typing of terminal medical record quality evaluation information;
The data transmission subsystem, it is a network transmission device, realizes data transmission and detection, extracts terminal medical record information and inpatient's essential information in the described data server subsystem, and is transported to described typing service terminal, realizes the mutual of data.
2, terminal medical record quality evaluation input system according to claim 1 is characterized in that: described data server subsystem comprises the Intranet that the exclusive data server forms and is arranged on wherein physical isolation apparatus.
3, terminal medical record quality evaluation input system according to claim 1 is characterized in that: described data transmission subsystem comprises two kinds of service channels of LAN (Local Area Network) and internet.
4, terminal medical record quality evaluation input system according to claim 2 is characterized in that: described exclusive data server adopts Dual-Computer Hot-Standby System, tape library data backup device.
5, a kind of terminal medical record quality evaluation input method, it is to realize that by above-mentioned terminal medical record quality evaluation input system it is characterized in that: it step that comprises has:
Step a: set up the database that stores terminal medical record information and inpatient's essential information data;
Step b: set up the ICD10 normal dictionary, set up Class A operation normal dictionary, set up the normal dictionary of single sick kind expense control, set up personnel's dictionary, set up quality of case history and estimate defective content and standard of deducting point normal dictionary;
Step c: land the typing service terminal, and get in touch with the foundation of data server subsystem;
Steps d: extract the Database Systems date automatically for date field; Automatically gather for medical record number and patient's name's data information system; For needing typing medical diagnosis on disease title and coding (ICD10), operation names, case history defective content, writing doctor, higher level doctor, supervisory personnel's field setup parameter coding;
Step e: extract and the analytic parameter coding, if parameter coding resolve successfully, execution in step f then, otherwise, execution in step h;
Step f: call corresponding database automatically according to resolving back parameter coding content, and according to the parameter coding content after resolving according to phonetic sign indicating number or constructive code retrieval, and the content after will selecting according to the parameter coding content after resolving is returned and is presented at automatically on the typing field;
Step g: according to the case history defective content of typing, according to the standard of deducting point of default, system judges the medical record grade automatically, and is presented on the medical record rank field; According to the operation names of typing, according to the Class A operation dictionary of default, system judges whether to be the Class A operation automatically; According to the medical diagnosis on disease title and the coding (ICD10) of typing, system judges whether to be single sick kind expense control case history automatically;
Step h: obtain the error message prompting;
Step I: typing is finished.
6, a kind of terminal medical record quality evaluation input method according to claim 5, it is characterized in that: described terminal medical record data message comprises: medical record number, patient's name, write doctor, higher level doctor, medical record grade, medical diagnosis on disease title and coding (ICD10), operation names, supervisory personnel, check data, case history defective content and standard of deducting point.
7, a kind of terminal medical record quality evaluation input method according to claim 5, it is characterized in that: described parameter coding comprises: call database-name, search criteria coding, return code field.
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| CN103218767A (en) * | 2013-03-27 | 2013-07-24 | 无锡曼荼罗软件有限公司 | Quality control method and system for clinical medical record |
| CN105786934A (en) * | 2014-12-26 | 2016-07-20 | 北大医疗信息技术有限公司 | Method and system for processing medical record document |
| 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 |
| CN106250668A (en) * | 2016-07-06 | 2016-12-21 | 无锡市疾病预防控制中心 | The Notifiable diseases such as hand-foot-mouth disease influenza are anti-fails to report management system and method |
| CN107945840A (en) * | 2017-11-02 | 2018-04-20 | 刘莉 | The evaluation method and device of electronic health record |
| CN107978343A (en) * | 2017-11-02 | 2018-05-01 | 刘莉 | The evaluation system of electronic health record |
| CN108389621A (en) * | 2018-02-08 | 2018-08-10 | 山东康网网络科技有限公司 | Medical record database quality determining method and system |
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2008
- 2008-05-17 CN CNA2008100162509A patent/CN101582100A/en active Pending
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| CN103218767A (en) * | 2013-03-27 | 2013-07-24 | 无锡曼荼罗软件有限公司 | Quality control method and system for clinical medical record |
| CN105786934B (en) * | 2014-12-26 | 2020-06-12 | 北大医疗信息技术有限公司 | Medical record document defect processing method and system |
| CN105786934A (en) * | 2014-12-26 | 2016-07-20 | 北大医疗信息技术有限公司 | Method and system for processing medical record document |
| 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 |
| CN106250668A (en) * | 2016-07-06 | 2016-12-21 | 无锡市疾病预防控制中心 | The Notifiable diseases such as hand-foot-mouth disease influenza are anti-fails to report management system and method |
| CN107945840A (en) * | 2017-11-02 | 2018-04-20 | 刘莉 | The evaluation method and device of electronic health record |
| CN107978343A (en) * | 2017-11-02 | 2018-05-01 | 刘莉 | The evaluation system of electronic health record |
| CN108389621A (en) * | 2018-02-08 | 2018-08-10 | 山东康网网络科技有限公司 | Medical record database quality determining method and system |
| CN108389621B (en) * | 2018-02-08 | 2020-08-04 | 山东康网网络科技有限公司 | Method and system for detecting data quality of first page of medical record |
| CN109615227A (en) * | 2018-12-12 | 2019-04-12 | 泰康保险集团股份有限公司 | Medical institutions' annual appraisal result method, apparatus, medium and electronic equipment |
| CN110162779A (en) * | 2019-04-04 | 2019-08-23 | 北京百度网讯科技有限公司 | Appraisal procedure, device and the equipment of quality of case history |
| CN110162779B (en) * | 2019-04-04 | 2023-08-04 | 北京百度网讯科技有限公司 | Medical record quality evaluation method, device and equipment |
| CN110808089A (en) * | 2019-10-16 | 2020-02-18 | 云知声智能科技股份有限公司 | Method and device for displaying defect number under document catalog |
| CN110808089B (en) * | 2019-10-16 | 2022-04-01 | 云知声智能科技股份有限公司 | Method and device for displaying defect number under document catalog |
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Open date: 20091118 |