CN101714191A - Quality control method and device for electronic medical records - Google Patents
Quality control method and device for electronic medical records Download PDFInfo
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- CN101714191A CN101714191A CN200910206461A CN200910206461A CN101714191A CN 101714191 A CN101714191 A CN 101714191A CN 200910206461 A CN200910206461 A CN 200910206461A CN 200910206461 A CN200910206461 A CN 200910206461A CN 101714191 A CN101714191 A CN 101714191A
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Abstract
The invention discloses quality control method and device for electronic medical records. The method comprises the following steps of obtaining a medical record check rule set by a user; and analyzing the medical record appointed by the user according to the medical record check rule, and outputting the analysis result. The device comprises a rule acquiring module and a medical record analyzing module. The invention can perform quality check on the electronic medical records according to the medical record check rule appointed by the user, effectively enhance the efficiency of the electronic medical record check, and improve the accuracy and reliability of the electronic medical records.
Description
Technical field
The present invention relates to the electronic health record field of quality control, particularly relate to a kind of method of quality control and device of electronic health record.
Background technology
Case history is all archives of medical treatment prescription on individual diagnosis of record patient, be the medical worker by outpatient service, have a medical check-up, the data the most intuitively that curative activity obtained such as auxiliary examination, diagnosis, treatment and nursing, particularly along with development of computer, electronic health record has become an important form of medical history record.Because being hospital, case history is used to the foundation estimating patient or patient health is diagnosed targetedly, having relatively high expectations of medical history record, the quality of case history directly affects the diagnosis of hospital to patient health, and electronic health record relates to operations such as a large amount of stickups, copy when record, therefore, how the quality of electronic health record is checked or controls to be very important.
Because case history need be put down in writing a large amount of relevant patients' medical information, and in electronic health record manufacturing process, because staff's error, perhaps other reason, cause the medical history record mistake easily, thereby influence the authenticity and the reliability of case history, and, because requiring of the medical information of electronic health record record is more, as to the requirement of time, to the requirement of recorded information order and to requirement of recorded content etc., in addition, also inequality to the requirement of information such as different section office, various disease, make that the quality control of electronic health record is relatively more difficult.At present, quality control at electronic health record generally is to be undertaken by the form of artificial selective examination, promptly according to the artificial form of spot-check case history, check whether to exist in the case and fail to fill in, fill in mistake or fill in situations such as obviously against regulation, to judge the quality of case history, this mode quality of case history control adopts the form of sampling observation to carry out, can't check all a large amount of electronic health records, thereby also can't reach control electronic health record effect, and check by manually carrying out, must strengthen artificial workload, and artificial factor has also reduced the accuracy of quality check.In addition, in the prior art, also with good grounds every kind of quality control rule at this disease specific of the formulation of disease particularly, promptly the case history of concrete disease is checked according to the rule of this formulation, but, this mode also can only be checked case history particularly, its applicability is relatively poor, because the quantity of the electronic health record of hospital record is huge, the kind of various disease is more, different case history inspections are inequality, and this kind mode also can't be controlled the accuracy and the reliability of electronic health record record effectively.
To sum up, in the quality control of prior art electronic health record, adopt the form of artificial selective examination to carry out the electronic health record quality control, need the waste great amount of manpower, the weak effect of quality control, and advance to adopt the form of selective examination to control to the quality of whole electronic health record, the electronic health record checking efficiency is low.
Summary of the invention
The method of quality control and the device that the purpose of this invention is to provide a kind of electronic health record can effectively be checked the quality of electronic health record and control, and improve the accuracy and the reliability of electronic health record quality control, improve the efficient of electronic health record quality check.
For achieving the above object, the invention provides a kind of method of quality control of electronic health record, comprising:
Obtain the case history inspection rule that the user sets;
According to described case history inspection rule the electronic health record of described user's appointment is analyzed, and the output analysis result.
Wherein, described case history inspection rule comprises that related paragraph checks that rule, paragraph disappearance check that rule, content disappearance check that rule, content character length constraint check that rule, paragraph time continuity check that rule, date contrast paragraph check in the periodic test rule of rule and paragraph one or multinomial.
Describedly comprise according to the electronic health record analysis of described case history inspection rule to described user's appointment:
Check rule according to described case history, check by the mode of inquiry or coupling whether described electronic health record satisfies described case history and check rule.
Described output analysis result comprises:
When described electronic health record does not satisfy described case history and checks rule, paragraph or the content identification of not satisfying described case history inspection rule in the described electronic health record are come out, check or revise for the user.
The present invention also provides a kind of quality control apparatus of electronic health record, comprising:
Rule acquisition module is used to obtain the case history inspection rule that the user sets;
The analysis of medical record module is used for according to described case history inspection rule the electronic health record of described user's appointment being analyzed, and the output analysis result.
The quality control apparatus of described electronic health record also comprises: regular setting module, be used to receive every inspection rule of user's input, and every inspection rule of described user input combined form described case history and check rule, wherein, check that rule comprises that related paragraph checks that rule, paragraph disappearance check that rule, content disappearance check that rule, content character length constraint check that rule, paragraph time continuity check that rule, date contrast paragraph check in the periodic test rule of rule and paragraph one or multinomial.
Described analysis of medical record module comprises:
Analytic unit is used for checking rule according to described case history, checks by the mode of inquiry or coupling whether described electronic health record satisfies described case history and check rule;
Output unit is used for when described electronic health record does not satisfy described case history and checks rule paragraph or the content identification of not satisfying described case history inspection rule in the described electronic health record being come out, and checks or revises for the user.
The present embodiment technical scheme is carried out quality check according to the case history inspection rule that the user sets to electronic health record, and electronic health record quality check process is carried out automatically, do not need artificial, a large amount of manpowers have been saved, can effectively improve the efficient that electronic health record is checked, improve the accuracy and the reliability of electronic health record quality control; In the present embodiment, the user can set suitable case history according to the needs of oneself and check rule, make and the more pointed and applicability of inspection of electronic health record in the quality check applicable to various electronic health records, make the inspection of electronic health record have stronger applicability and reliability.
Description of drawings
In order to be illustrated more clearly in the embodiment of the invention or technical scheme of the prior art, to do one to the accompanying drawing of required use in embodiment or the description of the Prior Art below introduces simply, apparently, accompanying drawing in describing below is some embodiments of the present invention, for those of ordinary skills, under the prerequisite of not paying creative work, can also obtain other accompanying drawing according to these accompanying drawings.
Fig. 1 is the process flow diagram of the method for quality control embodiment of electronic health record of the present invention;
Fig. 2 is the structural representation of the quality control apparatus embodiment of electronic health record of the present invention;
Fig. 3 is the structural representation of analysis of medical record module among the quality control apparatus embodiment of electronic health record of the present invention.
Embodiment
For the purpose, technical scheme and the advantage that make the embodiment of the invention clearer, below in conjunction with the accompanying drawing in the embodiment of the invention, technical scheme in the embodiment of the invention is clearly and completely described, obviously, described embodiment is the present invention's part embodiment, rather than whole embodiment.Based on the embodiment among the present invention, those of ordinary skills belong to the scope of protection of the invention not making the every other embodiment that is obtained under the creative work prerequisite.
The embodiment of the invention can be applicable in the quality check and control of electronic health record, can control the quality of electronic health record effectively, improve the accuracy and the reliability of electronic health record quality control, particularly, the embodiment of the invention can be checked electronic health record according to user-defined case history inspection rule, to confirm the electronic health record recording quality.
Fig. 1 is the process flow diagram of the method for quality control embodiment of electronic health record of the present invention.Particularly, as shown in Figure 1, the present embodiment method comprises the steps:
In the above-mentioned steps 101, described case history inspection rule can be specified by the user, and this case history inspection rule can comprise that specifically related paragraph checks that rule, paragraph disappearance check that rule, content disappearance check that rule, content character length constraint check that rule, paragraph time continuity check that rule, date contrast paragraph check in the periodic test rule of rule and paragraph one or multinomial.Particularly, because the form of electronic health record record and the content of record all are to carry out according to the standard of medical history record, therefore, the regularization term of respectively checking in the case history inspection rule in the present embodiment is the abstract logic rules of coming out of content according to clinical case history record, electronic health record according to the various disease that writes down, the user can set or the multinomial rule of checking as electronic health record in the above-mentioned inspection regularization term, electronic health record is checked, with the quality of control electronic health record.In addition, in the present embodiment, described case history inspection rule also can comprise the related rule of checking of doctor's advice.
Below the every inspection rule that relates in the present embodiment is described, present embodiment there is better understanding.
(1) related paragraph is checked rule, is used to check whether relevant paragraph coexists.Because many paragraphs of case history must be common the existence, as " transfer note " and " section's of connecing record ", perhaps, " discussion before the art ", " operation letter of consent ", " operation record ", " anesthesia record " and " postoperative course of disease record first " etc., therefore, be to exist to be mutually related between the part paragraph in the electronic health record, therefore, can check the relevant related paragraph in the electronic health record according to this association paragraph inspection rule, whether complete to determine the electronic health record record.
(2) the paragraph disappearance is checked rule, is used for the paragraph of checking that case history must exist.Because some paragraph in the electronic health record is to embody and to put down in writing in case history, as " RAN ", " case history of being admitted to hospital ", " course of disease record first of being admitted to hospital " and paragraphs such as " discharge abstracts ".Therefore, check rule, can lack inspection, to determine electronic health record writes down whether complete sum is reliable to the paragraph that must put down in writing in the case history by the paragraph disappearance of setting.
(3) the content disappearance is checked rule, is used to check whether the content in certain path lacks, and whether complete sum is reliable to determine the electronic health record content record.Wherein, electronic health record can be made up of following paragraph: first page of illness case, RAN, course of disease record and discharge abstract, course of disease record comprise the record of making the rounds of the wards, operation record, state of an illness discussion and the family members several types such as record of talking, and are referred to as the course of disease and record.The beginning of each paragraph in the electronic health record all has writing time, is a paths associated with each other between these paragraphs of electric power case history, therefore, can check whether search each paragraph in this path of electronic health record all exists.
(4) content character length constraint is checked rule, is used to check whether the content in certain path has surpassed maximum length.Because the content of some record is that certain length restriction is arranged in the case history, therefore, can check out whether put down in writing mistake in the case history effectively, to determine the whether accurate and reliable of electronic health record record by the content character length constraint inspection rule of setting.
(5) the paragraph time continuity is checked rule, is used to check whether the subsequent paragraph of part paragraph is set up in the time range of appointment.Because in the medical history record, other paragraph must be put down in writing in some paragraph back, and these subsequent paragraph should be set up in the time range after the date of last paragraph record, therefore, can check effectively that according to the paragraph time continuity inspection rule of setting whether the content of putting down in writing between the above-mentioned paragraph is accurately with reliable.
(6) date contrast paragraph is checked rule, is used to check whether some paragraph or element occurred in the fixed time of the paragraph of appointment.Wherein, specifying paragraph can comprise case history homepage and non-case history homepage, is the case history homepage as specifying paragraph, then in the admission date of the record of case history homepage, checks whether paragraph name, the structon key name content in time of appointment after this meets; If specifying paragraph is non-case history homepage, then writing time of this paragraph in contrast, other paragraph or content are checked.Therefore, check rule, can determine whether the electronic health record record is accurate and reliable according to the date contrast paragraph of this setting.
(7) the periodic test rule of paragraph, be used to check whether some paragraph occurs in the cycle of appointment, for example the course of disease record in operation back a period of time must be write once every day, inspection method is at first to find the position of operation record by keyword " operation record ", calculate the time interval of course of disease record thereafter then, surpass 1 day course of disease record paragraph.Each course of disease record all has a start time, and the time interval of course of disease record is exactly to deduct the time interval that the previous time is exactly two courses of disease records with the time that a back course of disease is recorded.
(8) the related rule of checking of doctor's advice is used for the time that the doctor's advice item according to appointment occurs, and case history paragraph or case history content is checked, to determine that whether accurately and reliable the electronic health record record.
In the above-mentioned steps 102, describedly comprise: check rule according to described case history, check by the mode of inquiry or coupling whether described electronic health record satisfies described case history and check rule according to the electronic health record analysis of described case history inspection rule to described user's appointment.In the present embodiment, when utilizing case history inspection rule that electronic health record is checked, can check that rule carry out in the mode of inquiry or coupling relevant paragraph or content, to check whether the paragraph put down in writing in the electronic health record or content satisfy each and check rule according to each.In addition, in step 102, described output analysis result comprises: when described electronic health record does not satisfy described case history and checks rule, paragraph or the content identification of not satisfying described case history inspection rule in the described electronic health record are come out, check or revise for the user, to guarantee integrality, accuracy and the reliability of electronic health record record.
In the present embodiment,, check rule, the electronic health record of appointment is checked,, improve electronic health record quality of stability and reliability with the quality of control electronic health record by the corresponding case history of User Defined according to different diseases or requirements of different users.As " infection of the upper respiratory tract " not being written as " going up sense " in the case history, then think term lack of standardization if " going up sense " occur.
The present embodiment technical scheme is carried out quality check according to the case history inspection rule that the user sets to electronic health record, and electronic health record quality check process is carried out automatically, do not need artificial, a large amount of manpowers have been saved, can effectively improve the efficient that electronic health record is checked, improve the accuracy and the reliability of electronic health record quality control; In the present embodiment, the user can set suitable case history according to the needs of oneself and check rule, make and the more pointed and applicability of inspection of electronic health record in the quality check applicable to various electronic health records, make the inspection of electronic health record have stronger applicability and reliability.
Fig. 2 is the structural representation of the quality control apparatus embodiment of electronic health record of the present invention.Particularly, as shown in Figure 2, the present embodiment device comprises rule acquisition module 1 and analysis of medical record module 2, and wherein, rule acquisition module 1 is used to obtain the case history inspection rule that the user sets; Analysis of medical record module 2 is used for according to the described case history inspection rule that described rule acquisition module 1 is obtained the electronic health record of described user's appointment being analyzed, and the output analysis result.
In addition, as shown in Figure 2, the present embodiment device also can comprise regular setting module 3, be used to receive every inspection rule of user's input, and every inspection rule of described user input combined form described case history and check rule, wherein, check that rule comprises that related paragraph checks that rule, paragraph disappearance check that rule, content disappearance check that rule, content character length constraint check that rule, paragraph time continuity check that rule, date contrast paragraph check in the periodic test rule of rule and paragraph one or multinomial.
In the present embodiment, the user can import the inspection rule of suitable quantities according to the needs of self by regular setting module 3,, with the checking respectively that regularization term combines and forms case history and check regularly of user input the electronic health record of user's appointment is checked by regular setting module 3.In addition, in the present embodiment, check that regularization term also can comprise the related rule of checking of doctor's advice, checks that with other regularization term realizes the quality of electronic health record is checked.
Fig. 3 is the structural representation of analysis of medical record module among the quality control apparatus embodiment of electronic health record of the present invention.Particularly, as shown in Figure 3, the analysis of medical record module 2 in the present embodiment can comprise analytic unit 21 and output unit 22, wherein, analytic unit 21 is used for checking rule according to described case history, checks by the mode of inquiry or coupling whether described electronic health record satisfies described case history and check rule; Output unit 22 is used for when described electronic health record does not satisfy described case history and checks rule paragraph or the content identification of not satisfying described case history inspection rule in the described electronic health record being come out, and checks or revises for the user.
The quality control apparatus of present embodiment electronic health record can be according to user's demand, can set suitable case history by regular setting module 3 by the user and check rule, and check by the electronic health record of 2 pairs of user's appointments of analysis of medical record module, wherein, the inspection of every rule in the described case history inspection rule is abstract various quality control logics of coming out, can carry out quality check to electronic health record by corresponding quality control logic, with accuracy and the reliability of guaranteeing that electronic health record is checked, improve the electronic health record checking efficiency, particularly, every inspection rule described in the present embodiment can not repeat them here with reference to described in the method for quality control of the invention described above embodiment electronic health record.
The present embodiment technical scheme is carried out quality check according to the case history inspection rule that the user sets to electronic health record, and electronic health record quality check process is carried out automatically, do not need artificial, a large amount of manpowers have been saved, can effectively improve the efficient that electronic health record is checked, improve the accuracy and the reliability of electronic health record quality control; In the present embodiment, the user can set suitable case history according to the needs of oneself and check rule, make and the more pointed and applicability of inspection of electronic health record in the quality check applicable to various electronic health records, make the inspection of electronic health record have stronger applicability and reliability.
One of ordinary skill in the art will appreciate that: all or part of step that realizes said method embodiment can be finished by the relevant hardware of programmed instruction, aforesaid program can be stored in the computer read/write memory medium, this program is carried out the step that comprises said method embodiment when carrying out; And aforesaid storage medium comprises: various media that can be program code stored such as ROM, RAM, magnetic disc or CD.
It should be noted that at last: above embodiment is only in order to technical scheme of the present invention to be described but not limit it, although the present invention is had been described in detail with reference to preferred embodiment, those of ordinary skill in the art is to be understood that: it still can make amendment or be equal to replacement technical scheme of the present invention, and these modifications or be equal to replacement and also can not make amended technical scheme break away from the spirit and scope of technical solution of the present invention.
Claims (9)
1. the method for quality control of an electronic health record is characterized in that, comprising:
Obtain the case history inspection rule that the user sets;
According to described case history inspection rule the electronic health record of described user's appointment is analyzed, and the output analysis result.
2. the method for quality control of electronic health record according to claim 1, it is characterized in that described case history inspection rule comprises that related paragraph checks that rule, paragraph disappearance check that rule, content disappearance check that rule, content character length constraint check that rule, paragraph time continuity check that rule, date contrast paragraph check in the periodic test rule of rule and paragraph one or multinomial.
3. the method for quality control of electronic health record according to claim 1 and 2 is characterized in that, describedly comprises according to the electronic health record analysis of described case history inspection rule to described user's appointment:
Check rule according to described case history, check by the mode of inquiry or coupling whether described electronic health record satisfies described case history and check rule.
4. the method for quality control of electronic health record according to claim 3 is characterized in that, described output analysis result comprises:
When described electronic health record does not satisfy described case history and checks rule, paragraph or the content identification of not satisfying described case history inspection rule in the described electronic health record are come out, check or revise for the user.
5. the method for quality control of electronic health record according to claim 2 is characterized in that, described case history inspection rule also comprises the related rule of checking of doctor's advice.
6. the quality control apparatus of an electronic health record is characterized in that, comprising:
Rule acquisition module is used to obtain the case history inspection rule that the user sets;
The analysis of medical record module is used for according to described case history inspection rule the electronic health record of described user's appointment being analyzed, and the output analysis result.
7. the quality control apparatus of electronic health record according to claim 6 is characterized in that, also comprises:
The rule setting module, be used to receive every inspection rule of user's input, and every inspection rule of described user input combined form described case history and check rule, wherein, check that rule comprises that related paragraph checks that rule, paragraph disappearance check that rule, content disappearance check that rule, content character length constraint check that rule, paragraph time continuity check that rule, date contrast paragraph check in the periodic test rule of rule and paragraph one or multinomial.
8. the quality control apparatus of electronic health record according to claim 7 is characterized in that, checks that rule also comprises the related rule of checking of doctor's advice.
9. the quality control apparatus of electronic health record according to claim 6 is characterized in that, described analysis of medical record module comprises:
Analytic unit is used for checking rule according to described case history, checks by the mode of inquiry or coupling whether described electronic health record satisfies described case history and check rule;
Output unit is used for when described electronic health record does not satisfy described case history and checks rule paragraph or the content identification of not satisfying described case history inspection rule in the described electronic health record being come out, and checks or revises for the user.
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| CN200910206461A CN101714191A (en) | 2009-11-13 | 2009-11-13 | Quality control method and device for electronic medical records |
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| CN200910206461A CN101714191A (en) | 2009-11-13 | 2009-11-13 | Quality control method and device for electronic medical records |
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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 |
| CN103577717A (en) * | 2013-11-25 | 2014-02-12 | 方正国际软件有限公司 | Content quality control device and method for medical history document |
| CN103646368A (en) * | 2013-11-25 | 2014-03-19 | 方正国际软件有限公司 | Real-time checking and correcting system and real-time checking and correcting method for medical record writing |
| CN104537497A (en) * | 2015-01-05 | 2015-04-22 | 国网河南省电力公司南阳供电公司 | Method for searching for unqualified work tickets of electric system |
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| 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 |
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| CN109887558A (en) * | 2018-12-29 | 2019-06-14 | 北京天鹏恒宇科技发展有限公司 | A kind of patient medical history quality control system |
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| CN103577717A (en) * | 2013-11-25 | 2014-02-12 | 方正国际软件有限公司 | Content quality control device and method for medical history document |
| CN103646368A (en) * | 2013-11-25 | 2014-03-19 | 方正国际软件有限公司 | Real-time checking and correcting system and real-time checking and correcting method for medical record writing |
| CN106714904B (en) * | 2014-10-22 | 2019-06-28 | 社会福祉法人三星生命公益财团 | Quality control system and method for radiotherapy unit |
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| 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 |
| CN107945840A (en) * | 2017-11-02 | 2018-04-20 | 刘莉 | The evaluation method and device of electronic health record |
| CN108564991A (en) * | 2018-04-13 | 2018-09-21 | 重庆医科大学附属儿童医院 | Digitization coding case history wrong identification system based on ICD and its recognition methods |
| CN109887558A (en) * | 2018-12-29 | 2019-06-14 | 北京天鹏恒宇科技发展有限公司 | A kind of patient medical history quality control system |
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| CN113052410A (en) * | 2019-12-26 | 2021-06-29 | 医渡云（北京）技术有限公司 | Quality control method and device for electronic medical record data |
| CN111180033A (en) * | 2019-12-31 | 2020-05-19 | 云知声智能科技股份有限公司 | Defect document display method and device |
| CN111180033B (en) * | 2019-12-31 | 2023-10-20 | 云知声智能科技股份有限公司 | Defect document display method and device |
| CN111681728A (en) * | 2020-06-09 | 2020-09-18 | 北京嘉和海森健康科技有限公司 | Content quality control method and device for electronic medical record |
| CN111681728B (en) * | 2020-06-09 | 2023-10-24 | 北京嘉和海森健康科技有限公司 | Content quality control method and device for electronic medical records |
| 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 |
| CN114566244A (en) * | 2022-03-25 | 2022-05-31 | 上海柯林布瑞信息技术有限公司 | Electronic medical record quality evaluation method and device and computer readable storage medium |
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