CN101908093A - Electronic medical record and method and system for controlling medical process on the basis of same - Google Patents
Electronic medical record and method and system for controlling medical process on the basis of same Download PDFInfo
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Abstract
The invention discloses an electronic medical record and a method and a system for controlling the medical process on the basis of the same. The method for controlling the medical process comprises the following steps of: establishing a medical path form frame according to medical dates or times; setting identity columns for multi-layer information items inside the medical path form frame; inputting medical template items into the medical path form frame according to disease kinds; executing or regulating the medical template items, and then carrying out digital signature confirmation; and combining executed medical template information into the electronic medical record according to a specified format. The invention provides the method for controlling the medical process of a disease by adopting a standard clinical path for doctors, thereby ensuring the medical quality; and in addition, the invention records and manages the information of the medical process, thereby generating the electronic medical record.
Description
Technical field
The present invention relates to electronic health record and electronic health record generating apparatus in the computer system, and the method and system of the disease medical procedure being controlled based on electronic health record.
Background technology
Traditional medical services provider is when providing medical services for the patient, mainly act with the ability and the experience of doctor's individuality, each doctor's knowledge background and experience have determined the quality and benefits of each medical events, though mechanisms such as hospital can and formulate the medical act of instructing doctor's individuality such as methods such as conventional treatments by training, but can not in medical procedure, provide reference method and corresponding prompt at any time, cause doctor's individuality when practical operation still based on the custom and experience; Different therapys does not have technological means to carry out objective comparison between the different doctors simultaneously, can't judge its quality, the therapy that causes can not in time obtain promoting, the therapy of difference can not obtain in time eliminating, young doctor can not avoid repeating to make a mistake and directly adopt good therapy, thereby influence quality of medical care and expense, caused the problem of the high cost of getting medical treatment, the difficulty and high cost of getting medical to a certain extent; Some governments or academic institution wish to come standard doctor's medical act by formulating the clinical path standard, but these clinical path standards all are based on the penman text type, can only lean on the memory and the understanding of doctor's individuality to instruct medical practice, can not instruct doctor's medical act at a clinical line; Mainly be that the mode that medical events is taked to write down is afterwards generated electronic health record at present, cause omission and inaccurate easily, incident on duty is not carried out digital signature timely simultaneously, be maliciously tampered easily, can not adapt to the needs of modern society.
Summary of the invention
First purpose of the present invention provides the medical procedure control technology, is used for medical service organ established standards medical path, the identical sick medical act of planting between different doctors of standard.
Second purpose of the present invention provides the electronic health record generation technique, is used for gathering the planned and execution incident of institute at medical procedure, and adopts digital signature technology to determine the trackability of plan maker and executor's behavior.
The 3rd purpose of the present invention is per diem to formulate Medical Forms so that this technology to be provided by planting for each is sick.
An advantage part of the present invention can be known by following description, another part can by embodiment should be used for know.
In order to achieve the above object, and according to the purpose of the present invention of general description here, electronic health record provided by the invention comprises Medical Forms, case history index, sequence number; Described Medical Forms comprise patient status's information, sick kind information, diagnosis information, management information, diagnostic message, fox message, material information, nursing information, treatment information, variation information, the status information of leaving hospital, medical expense information, digital signature information; Described case history index comprises patient's identity information, sick kind information, diagnosis information; Described sequence number comprises: the medical institutions' code of seeing and treating patients, time code, serial number.
Medical procedure control system provided by the invention comprises: the list framework maker of Lian Jieing successively, and sign hurdle maker, the medical treatment template maker, medical treatment template is carried out validator; Described list framework maker is used for by medical treatment day or the inferior medical path list framework of setting up; Described sign hurdle maker is used to the multi-layer information item in the above-mentioned list framework that the sign hurdle is set; Described medical treatment template maker is used for by the disease kind in list framework input medical treatment template project; Described medical treatment template is carried out validator, be used for adjusting or (with) carry out and give digital signature after the template item and confirm, the medical treatment template information after carrying out is pressed specified format synthesizes electronic health record.
In above-mentioned medical procedure control system, described list framework maker comprises: the block of information maker is used to the Medical Forms framework to set up gauge outfit block of information and Biao Li block of information; Gauge outfit Information maker is used to above-mentioned gauge outfit block of information to set up sick diagnosis, patient's identity, the diagnosis information hurdle of planting; The sick item of information maker of planting is used to above-mentioned sick kind Information to set up and comprises first diagnosis, compound second opinion item of information; Patient information item maker is used to above-mentioned patient's identity information hurdle to set up and comprises name, identity document title, passport NO., name of contact person, contact method item of information; Diagnosis information item maker is used to above-mentioned diagnosis information hurdle to set up to comprise the number of registering, the source of being in hospital, way of paying, the section office of being in hospital, the number information item of being in hospital; Information maker in the table is used in the above-mentioned table block of information to set up management, diagnosis, inspection, material, nursing, treatment, the state that makes a variation, leaves hospital, signing messages hurdle; The signature maker is used to above-mentioned signing messages hurdle to set up doctor, the nurse item of signing.
In above-mentioned medical procedure control system, described sign hurdle maker comprises: menu builder is used for setting up the menu selectionbar by predetermined item of information; Hurdle, space maker is used for setting up the hurdle, space by predetermined item of information; The banner maker is used for to item of information setting and comprises plan, cancellation, execution, the identification item that increases.
In above-mentioned medical procedure control system, described medical treatment template maker also comprises array apparatus down: the sick scrambler of planting is used for disease kind or its combination are encoded; The medical scheme setting apparatus is used for according to prior art medical scheme being formulated in disease kind or its combination of above-mentioned definition; Template generator is used for above-mentioned medical scheme is imported by the Medical Forms frame format.
In above-mentioned medical procedure control system, described medical treatment template is carried out validator and is also comprised array apparatus down: the medical record inducting device, be used for the coding of the medical record of seeing and treating patients is input to above-mentioned Medical Forms framework, and access corresponding medical treatment template; The deletion of items device is used for deleting this project in sign hurdle filling " cancellation "; Project increases device, and being used for increases new projects in sign hurdle filling " increase " or use enter key; The project validator is used for confirming this project in sign hurdle filling " plan "; Project implementation device, be used for after a project implementation, importing actuating code (with) or in sign hurdle filling " execution "; The signature device, be used for above-mentioned list frame content is carried out digital signature respectively by its maker or executor, electronic health record compositor: be used for above-mentioned executed list as content, gauge outfit information is as index, the medical institutions' code of seeing and treating patients of Lian Jieing successively, time code, serial number generate when time electronic health record as sequence number.
The present invention also provides the medical procedure control method, comprises the following steps: step 1: by medical treatment day or the inferior medical path list framework of setting up; Step 2: for the multi-layer information item in the above-mentioned list framework is provided with the sign hurdle; Step 3: in the list framework, import the medical treatment template project by sick the kind; Step 4: give the digital signature affirmation after carrying out or adjust template item, and the medical treatment template information after carrying out is pressed the synthetic electronic health record of specified format.
In the medical procedure control method, described step 1 comprises the following steps: step 11: for the Medical Forms framework is set up gauge outfit block of information and Biao Li block of information; Step 12: for setting up sick diagnosis, patient's identity, the diagnosis information hurdle of planting in above-mentioned gauge outfit block of information; Step 13: for the foundation of above-mentioned sick kind Information comprises first diagnosis, compound second opinion item of information; Step 14: for the foundation of above-mentioned patient's identity information hurdle comprises name, identity document title, passport NO., name of contact person, contact method item of information; Step 15: set up for above-mentioned diagnosis information hurdle comprise the number of registering, the source of being in hospital, way of paying, the section office of being in hospital, the number information item of being in hospital; Step 16: for setting up management, diagnosis, inspection, material, nursing, treatment, the state that makes a variation, leaves hospital, digital signature information hurdle in block of information in the above-mentioned table; Step 17: for setting up doctor, the nurse item of signing in above-mentioned digital signature information hurdle.
In the medical procedure control method, described step 2 comprises the following steps: step 21: to setting up the menu selectionbar by predetermined item of information; Step 22: to setting up the hurdle, space by predetermined item of information; Step 23: the sign hurdle that above-mentioned item of information setting is comprised plan, cancellation, execution, increase.
In the medical procedure control method, described step 3 comprises the following steps: step 31: disease kind or its combination are encoded; Step 32: medical scheme is formulated in disease kind or its combination of above-mentioned definition according to prior art; Step 33: above-mentioned medical scheme is pressed the input of Medical Forms form.
In the medical procedure control method, described step 4 comprises the following steps: step 41: the coding of the medical record of seeing and treating patients is input in the above-mentioned Medical Forms framework, accesses corresponding medical treatment template; Step 42: delete this project in sign hurdle filling " cancellation "; Step 43: increase new projects in sign hurdle filling " increase " or use enter key; Step 44: confirm this project in sign hurdle filling " plan "; Step 45: after a project implementation, import actuating code or identifying hurdle filling " execution "; Step 46: above-mentioned list frame content is carried out digital signature respectively by its maker or executor; Step 47: as content, gauge outfit information is as index above-mentioned executed list, the medical institutions' code of seeing and treating patients of Lian Jieing successively, and time code, serial number generate when time electronic health record as sequence number.
The present invention compared with prior art mainly contains following advantage:
The medical path that standard can be provided improves the accuracy that it formulates medical plan for doctor's reference.
The electronic health record Core Generator can be provided, can put down in writing all incidents, and carry out digital signature, guarantee the authenticity of medical procedure information, integrality, trackability by duty hour from the formulation medical plan to implementation.
Structurized electronic health record can be provided, support to generate index information, provide technical tool for medical record is further handled with gauge outfit information.
Description of drawings
Fig. 1 is the synoptic diagram of electronic health record of the present invention
Fig. 2 is a medical procedure control system inner structure synoptic diagram of the present invention
Fig. 3 is a list framework maker inner structure synoptic diagram among Fig. 2
Fig. 4 is a sign hurdle maker inner structure synoptic diagram among Fig. 2
Fig. 5 is a medical template generator inner structure synoptic diagram among Fig. 2
Fig. 6 is that medical treatment template is carried out validator inner structure synoptic diagram among Fig. 2
Fig. 7 is a medical procedure control method schematic flow diagram of the present invention
Fig. 8 is by medical treatment day or the inferior medical path list framework process flow diagram of setting up among Fig. 7
Fig. 9 is provided with sign hurdle process flow diagram for the multi-layer information item in the Medical Forms framework among Fig. 7
Figure 10 imports medical treatment template project process flow diagram by the disease kind among Fig. 7 in the Medical Forms framework
Figure 11 gives the digital signature affirmation after carrying out or adjust template item, and the medical treatment template information after carrying out is pressed the synthetic electronic health record process flow diagram of specified format
Figure 12 is a medical procedure control system topology synoptic diagram of the present invention
Embodiment
The present invention is described in further detail below in conjunction with embodiment and accompanying drawing, but embodiments of the present invention are not limited thereto.
Embodiment
As shown in Figure 1, electronic health record of the present invention is meant the packet that produces and circulate with the electronic data form by certain format; Specifically comprise Medical Forms, the case history index, the case history sequence number, wherein Medical Forms are according to papery prescription or doctor's advice and dispose single institute and comprise information and make, mainly comprise disease kind information, patient status's information, diagnosis information, management information, diagnostic message, fox message, material information, nursing information, treatment information, variation information, the status information of leaving hospital, medical expense information, digital signature information, wherein the case history index comprises disease kind information, patient status's information, diagnosis information, the case history call number comprises the Institution Code of seeing and treating patients, go to a doctor or the time code of leaving hospital, the prescription on individual diagnosis serial number.
As shown in Figure 2, medical procedure control system of the present invention comprises: the list framework maker 201 of Lian Jieing successively, and sign hurdle maker 202, medical treatment template maker 203, medical treatment template is carried out validator 204; Implementation method comprises sets up two layer architectures, realize importing and receiving the interface of information with presentation layer (UI) technology, comprise the list framework, the sign hurdle, the generation of medical treatment template and execution interface, the Windows forms technology (comprising the order line forms) under the C/S framework for example, also has the web page technology (comprising synchronistic model and asynchronous model technology) under the B/S framework, use data access layer (DAL) technology to realize above-mentioned storage and visit again to input in the interface and reception data, comprise and generate database table (DB2 for example, SQL2000, ORACL10), it also can be structural type file (XML file for example, the EXCEL file), can also be that (for example WORD WPS), can be a binary file to text again; By start the service logic of whole medical control system in presentation layer input template information, realize control, and control procedure and object information are generated electronic health record medical procedure.
Fig. 3 is a list framework maker inner structure synoptic diagram among Fig. 2, comprising: the block of information maker 3011 of setting up gauge outfit block of information and Biao Li block of information for the Medical Forms framework; For setting up sick gauge outfit Information maker 3012 of planting diagnosis, patient's identity, diagnosis information hurdle in above-mentioned gauge outfit block of information; For the above-mentioned sick Information of planting is set up the disease kind item of information maker 3013 that comprises first diagnosis, compound second opinion item of information; Set up the patient information item maker 3014 that comprises name, identity document title, passport NO., name of contact person, contact method item of information for above-mentioned patient's identity information hurdle; Set up for above-mentioned diagnosis information hurdle comprise the number of registering, the diagnosis information item maker 3015 of the source of being in hospital, way of paying, the section office of being in hospital, the number information item of being in hospital; Set up Information maker 3016 in the table of management, diagnosis, inspection, material, nursing, treatment, the state that makes a variation, leaves hospital, medical expense Information for block of information in the above-mentioned table and confirm owner's signature maker 3017, can also set up multilayer subordinate menu again for above-mentioned Information for above-mentioned project; Implementation method can be to realize importing and receiving the interface of information with presentation layer (UI) technology, the interface that comprises list framework, multi-menu, the Windows forms technology (comprising the order line forms) under the C/S framework for example, also having the web page technology (comprising synchronistic model and asynchronous model technology) under the B/S framework, for example is documentwindow or image window or structural type menu or sign hurdle window; Use data access layer (DAL) technology to realize above-mentioned storage and visit again to input in the interface and reception data, comprise and generate corresponding database table (DB2 for example, SQL2000, ORACL10), also can be structural type file (for example XML file, EXCEL file), can also be text (WORD for example, WPS), can be binary file (image file) again.
Fig. 4 is a sign hurdle maker inner structure synoptic diagram among Fig. 2, comprising: for can predetermined item of information setting up the menu builder 3021 of menu selectionbar; For setting up hurdle, space, hurdle, space maker 3022 by predetermined item of information; The banner maker 3023 that comprises the identification item of plan, cancellation, execution, increase for the item of information setting, implementation method can realize importing and receiving the interface of information with presentation layer (UI) technology, the interface that comprises menu, hurdle, space, identification item, the Windows forms technology (comprising the order line forms) under the C/S framework for example, also having the web page technology (comprising synchronistic model and asynchronous model technology) under the B/S framework, for example is documentwindow or image window or structural type menu or sign hurdle window; Use data access layer (DAL) technology to realize above-mentioned storage and visit again to input in the interface and reception data, comprise and generate corresponding database table (DB2 for example, SQL2000, ORACL10), also can be structural type file (for example XML file, EXCEL file), can also be text (WORD for example, WPS), can be binary file (image file) again.
Fig. 5 is a medical template generator inner structure synoptic diagram among Fig. 2, comprise: the disease kind scrambler 3031 of encoding for disease kind or its combination, according to the medical scheme designer 3032 that prior art is formulated medical scheme to disease kind or its combination of above-mentioned definition, above-mentioned medical scheme is pressed the template generator 3033 of Medical Forms frame format input; Sick kind scrambler 3031 implementation methods can be to set up database table or structural type file or text or binary file, and ill kind of title of institute and its coding are set up corresponding relation; The implementation method of medical scheme designer 3032 can be to set up database table or structural type file or text or binary file, the medical scheme of ill kind and its coding or title be mapped, medical scheme can directly adopt prior art, also can employ new technology, the implementation method of template generator 3033 can be to set up two layer architectures, the interface of realizing medical treatment template with presentation layer (UI) technology, the Windows forms technology (comprising the order line forms) under the C/S framework for example, also have the web page technology (comprising synchronistic model and asynchronous model technology) under the B/S framework, use data access layer again
(DAL) technology realizes above-mentioned storage and visit to input in the interface and reception data, comprise and generate database table (DB2 for example, SQL2000, ORACL10), also can be structural type file (for example XML file, EXCEL file), can also be text (WORD for example, WPS), can be that above-mentioned storehouse table and file are used in binary file or mixing again.
Fig. 6 is that medical treatment template is carried out validator inner structure synoptic diagram among Fig. 2, comprising: for accessing the medical record inducting device 3041 of corresponding medical treatment template; For deleting the deletion of items device 3042 of a project; For the project that increases new projects increases device 3043; For confirming the project validator 3044 of this project; For identifying the project implementation device 3045 that a project has been carried out; For above-mentioned list frame content is carried out the signature device 3046 of digital signature respectively by its maker or executor, for above-mentioned executed list being generated electronic health record compositor 3047 when time electronic health record; Medical record inducting device 3041 implementation methods can be by menu in disease kind code database table or file, select a title or (with) coding, also can by the hurdle, space receive a title or (with) coding; The implementation method of deletion of items device 3042 can be in the click " cancellation " of sign hurdle, and marks this project " cancellation " attribute in medical treatment template storehouse table or file; The implementation method that project increases device 3043 can be to use click " increase " or use enter key on the sign hurdle, selects the project that will increase and marks this project " increase " attribute in medical treatment template storehouse table or file; The implementation method of project validator 3044 can be in the click " plan " of sign hurdle, and marks this project " plan " attribute in medical treatment template storehouse table or file; The implementation method of project implementation device 3045 can be to read project implementation coding, executor's coding, be performed the mode of coding with click " executions " or by scanner scanning or reader on the sign hurdle, and the medical treatment template storehouse show or file in mark this project " executed " attribute; The implementation method of signature device 3046 can be to adopt the technology of ISO/TC68 definition, for example with digital signature the plan template or the numbering sign indicating number of above-mentioned medical record is signed; Also can be compressed into summary to foregoing or numbering sign indicating number with compression function (for example HASH function), with digital signature above-mentioned summary is signed again, can also be and the method for reserving the checking of user name and PIN (Personal Identification Number), can be again from subscriber card (IC-card or magnetic stripe card or USB flash disk) read subscriber identity information again with the PIN (Personal Identification Number) pair verification method of reserving, more can be to read the method that subscriber identity information is not done checking from subscriber card (IC-card or magnetic stripe card or USB flash disk), numbering can adopt modes such as numeral or letter, gauge outfit information or internal information of statement represented in for example preceding one-bit digital or letter, second or two or three numerals or the alphabetical item of information of representing the place, the 3rd or four or five numerals or the alphabetical thin item of information of representing the place, can also segment down again, 20605 the 5th thin projects of representing in the treatment project of internal information of statement for example, the coding of adding thin project is exactly corresponding numbering sign indicating number; The implementation method of electronic health record compositor 3047 can be generate a database table (DB2 for example, SQL2000, ORACL10), perhaps structural type file (for example XML file, EXCEL file), perhaps text (WORD for example, WPS), perhaps binary file, the gauge outfit item of information as index entry, the medical institutions' code of seeing and treating patients successively, time code, serial number as content, is just formed this electronic health record to executed Medical Forms as sequence number.
Fig. 7 is a medical procedure control method schematic flow diagram of the present invention, this flow process comprises: step S 1 is by medical treatment day or the inferior medical path list framework of setting up, multi-layer information item in step S2 is above-mentioned list framework is provided with the sign hurdle, in above-mentioned list framework, import the medical treatment template project at step S3 by sick the kind, after step S4 carries out or adjusts template item, give digital signature and confirm, and the medical treatment template information after carrying out is pressed the synthetic electronic health record of specified format.
Fig. 8 be among Fig. 7 by the medical treatment day or the inferior medical path list framework process flow diagram of setting up, specifically comprise following step: set up gauge outfit block of information and Biao Li block of information for the Medical Forms framework at step S11; Be that sick diagnosis, patient's identity, the diagnosis information hurdle of planting set up in above-mentioned gauge outfit block of information at step S12; Be that the foundation of above-mentioned sick kind Information comprises first diagnosis, compound second opinion item of information at step S13; At step S14 is that the foundation of above-mentioned patient's identity information hurdle comprises name, identity document title, passport NO., name of contact person, contact method item of information; Step S15 be above-mentioned diagnosis information hurdle set up comprise the number of registering, the source of being in hospital, way of paying, the section office of being in hospital, the number information item of being in hospital; At step S16 is that management, diagnosis, inspection, material, nursing, treatment, the state that makes a variation, leaves hospital, medical expense Information are set up in the block of information in the above-mentioned table, at step S17 is that above-mentioned project is confirmed the owner, can also set up multilayer subordinate menu again for above-mentioned Information; Implementation method can be to realize importing and receiving the interface of information with presentation layer (UI) technology, the interface that comprises list framework, multi-menu, the Windows forms technology (comprising the order line forms) under the C/S framework for example, also having the web page technology (comprising synchronistic model and asynchronous model technology) under the B/S framework, for example is documentwindow or image window or structural type menu or sign hurdle window; Use data access layer (DAL) technology to realize above-mentioned storage and visit again to input in the interface and reception data, comprise and generate corresponding database table (DB2 for example, SQL2000, ORACL10), also can be structural type file (for example XML file, EXCEL file), can also be text (WORD for example, WPS), can be binary file (image file) again.
Fig. 9 be among Fig. 7 for the multi-layer information item in the Medical Forms framework is provided with sign hurdle process flow diagram, specifically comprise following step: at step S21 for setting up the menu selectionbar by predetermined item of information; At step S22 for setting up the hurdle, space by predetermined item of information; The identification item that comprises plan, cancellation, execution, increase at step S23 for the item of information setting, implementation method can realize importing and receiving the interface of information with presentation layer (UI) technology, the interface that comprises menu, hurdle, space, identification item, the Windows forms technology (comprising the order line forms) under the C/S framework for example, also having the web page technology (comprising synchronistic model and asynchronous model technology) under the B/S framework, for example is documentwindow or image window or structural type menu or sign hurdle window; Use data access layer (DAL) technology to realize above-mentioned storage and visit again to input in the interface and reception data, comprise and generate corresponding database table (DB2 for example, SQL2000, ORACL10), also can be structural type file (for example XML file, EXCEL file), can also be text (WORD for example, WPS), can be binary file (image file) again.
Figure 10 imports medical treatment template project process flow diagram by the disease kind among Fig. 7 in the Medical Forms framework, specifically comprise following step: at step S31 is that sick kind or its combination are encoded; According to prior art medical scheme is formulated in disease kind or its combination of above-mentioned definition at step S32; At step S33 above-mentioned medical scheme is pressed the input of Medical Forms frame format; Step S31 implementation method can be to set up database table or structural type file or text or binary file, and ill kind of title of institute and its coding are set up corresponding relation; The implementation method of step S32 can be to set up database table or structural type file or text or binary file, the medical scheme of ill kind and its coding or title be mapped, medical scheme can directly adopt prior art, also can employ new technology, the implementation method of step S33 can be to set up two layer architectures, the interface of realizing medical treatment template with presentation layer (UI) technology, the Windows forms technology (comprising the order line forms) under the C/S framework for example, also has the web page technology (comprising synchronistic model and asynchronous model technology) under the B/S framework, use data access layer (DAL) technology to realize above-mentioned storage and visit again to input in the interface and reception data, comprise and generate database table (DB2 for example, SQL2000, ORACL10), also can be structural type file (for example XML file, EXCEL file), can also be text (WORD for example, WPS), can be that above-mentioned storehouse table and file are used in binary file or mixing again.
Figure 11 gives the digital signature affirmation after carrying out or adjust template item, and the medical treatment template information after carrying out is pressed the synthetic electronic health record process flow diagram of specified format, specifically comprises following step: access corresponding medical treatment template in step S41; In project of step S42 deletion; Increase new projects at step S43; Confirm this project at step S44; Identify a project for carrying out at step S45; At step S46 for above-mentioned list frame content is carried out digital signature respectively by its maker or executor; At step S47 is that above-mentioned executed list is generated when time electronic health record; Step S41 implementation method can be by menu in disease kind code database table or file, select a title or (with) coding, also can by the hurdle, space receive a title or (with) coding; The implementation method of step S42 can be in the click " cancellation " of sign hurdle, and marks this project " cancellation " attribute in medical treatment template storehouse table or file; The implementation method of step S43 can be to use click " increase " or use enter key on the sign hurdle, and the project of selecting to increase in medical treatment template storehouse table or file also marks this project " increase " attribute; The implementation method of step S44 can be in the click " plan " of sign hurdle, and marks this project " plan " attribute in medical treatment template storehouse table or file; The implementation method of step S45 can be to read project implementation coding, executor's coding, be performed the mode of coding with click " executions " or by scanner scanning or reader on the sign hurdle, and the medical treatment template storehouse show or file in mark this project " executed " attribute; The implementation method of step S46 can be to adopt the technology of ISO/TC68 definition, for example with digital signature the plan template or the numbering sign indicating number of above-mentioned medical record is signed; Also can be compressed into summary to foregoing or numbering sign indicating number with compression function (for example HASH function), with digital signature above-mentioned summary is signed again, can also be and the method for reserving the checking of user name and PIN (Personal Identification Number), can be again from subscriber card (IC-card or magnetic stripe card or USB flash disk) read subscriber identity information again with the PIN (Personal Identification Number) pair verification method of reserving, more can be to read the method that subscriber identity information is not done checking from subscriber card (IC-card or magnetic stripe card or USB flash disk), numbering can adopt modes such as numeral or letter, gauge outfit information or internal information of statement represented in for example preceding one-bit digital or letter, second or two or three numerals or the alphabetical item of information of representing the place, the 3rd or four or five numerals or the alphabetical thin item of information of representing the place, can also segment down again, 20605 the 5th thin projects of representing in the treatment project of internal information of statement for example, the coding of adding thin project is exactly corresponding numbering sign indicating number; The implementation method of step S47 can be generate a database table (DB2 for example, SQL2000, ORACL10), perhaps structural type file (for example XML file, EXCEL file), perhaps text (WORD for example, WPS), perhaps binary file, the gauge outfit item of information as index entry, the medical institutions' code of seeing and treating patients successively, time code, serial number as content, is just formed this electronic health record to executed Medical Forms as sequence number.
Figure 12 is a medical procedure control system topology synoptic diagram of the present invention, medical procedure control system as shown in figure 12 comprises CPU (CPU (central processing unit)) 1201, RAM (random access memory) 1202, ROM (ROM (read-only memory)) 1203, system bus 1204, HD (hard disk) controller 1205, keyboard controller 1206, serial interface controller 1207, parallel interface controller 1208, display controller 1209 and mouse controller 1210.Hard disk 1211 links to each other with HD (hard disk) controller 1205, keyboard 1212 links to each other with keyboard controller 1206, card reader or USB flash disk or bar code or RFID reader 1213 and serial interface controller 1207, printer 1214 links to each other with parallel interface controller 1208, display 1215 links to each other with display controller 1209, and mouse 1216 links to each other with mouse controller 1210.
Topological structure shown in Figure 12 is not only applicable to personal computer, and is applicable to workstation, large, medium and small type computing machine, and hand-hold electronic equipments, for example palm PC, PDA (personal digital assistant).In different application, some parts shown in Figure 12 can be omitted or be extended to a plurality of, can be extended to a plurality of USB (universal serial port bus) interface as serial interface controller 1207.
Total system shown in Figure 12 is by being stored in the computer-readable instruction control that (perhaps is stored in EPROM or other nonvolatile memories) in the hard disk 1211 as software usually.Software can perhaps be stored in the hard disk 1211 from the network download (not shown), and perhaps the software from network download can be loaded into RAM1202, and is carried out by CPU1201, so that finish the function of being determined by software.
The foregoing description is a preferred implementation of the present invention; but embodiments of the present invention are not restricted to the described embodiments; other any do not deviate from change, the modification done under spirit of the present invention and the principle, substitutes, combination, simplify; all should be the substitute mode of equivalence, be included within protection scope of the present invention.
Claims (11)
1. electronic health record is characterized in that: comprise Medical Forms, case history index, sequence number; Described Medical Forms comprise patient status's information, sick kind information, diagnosis information, management information, diagnostic message, fox message, material information, nursing information, treatment information, variation information, the status information of leaving hospital, medical expense information, digital signature information; Described case history index comprises patient's identity information, sick kind information, diagnosis information; Described sequence number comprises: the medical institutions' code of seeing and treating patients, time code, serial number.
2. medical procedure control system is characterized in that comprising: the list framework maker of Lian Jieing successively, and sign hurdle maker, the medical treatment template maker, medical treatment template is carried out validator; Described list framework maker is used for by medical treatment day or the inferior medical path list framework of setting up; Described sign hurdle maker is used to the multi-layer information item in the above-mentioned list framework that the sign hurdle is set; Described medical treatment template maker is used for by the disease kind in list framework input medical treatment template project; Described medical treatment template is carried out validator, be used for adjusting or (with) carry out and give digital signature after the template item and confirm, the medical treatment template information after carrying out is pressed specified format synthesizes electronic health record.
3. system as claimed in claim 2 is characterized in that described list framework maker comprises:
The block of information maker is used to the Medical Forms framework to set up gauge outfit block of information and Biao Li block of information;
Gauge outfit Information maker is used to above-mentioned gauge outfit block of information to set up sick diagnosis, patient's identity, the diagnosis information hurdle of planting;
The sick item of information maker of planting is used to above-mentioned sick kind Information to set up and comprises first diagnosis, compound second opinion item of information;
Patient information item maker is used to above-mentioned patient's identity information hurdle to set up and comprises name, identity document title, passport NO., name of contact person, contact method item of information;
Diagnosis information item maker is used to above-mentioned diagnosis information hurdle to set up to comprise the number of registering, the source of being in hospital, way of paying, the section office of being in hospital, the number information item of being in hospital;
Information maker in the table is used in the above-mentioned table block of information to set up management, diagnosis, inspection, material, nursing, treatment, the state that makes a variation, leaves hospital, signing messages hurdle;
The signature maker is used to above-mentioned signing messages hurdle to set up doctor, the nurse item of signing.
4. system as claimed in claim 2 is characterized in that described sign hurdle maker comprises:
Menu builder is used for setting up the menu selectionbar by predetermined item of information;
Hurdle, space maker is used for setting up the hurdle, space by predetermined item of information;
The banner maker is used for to item of information setting and comprises plan, cancellation, execution, the identification item that increases.
5. system as claimed in claim 2 is characterized in that described medical treatment template maker also comprises array apparatus down:
The sick scrambler of planting is used for disease kind or its combination are encoded;
The medical scheme setting apparatus is used for according to prior art medical scheme being formulated in disease kind or its combination of above-mentioned definition;
Template generator is used for above-mentioned medical scheme is imported by the Medical Forms frame format.
6. system as claimed in claim 2 is characterized in that described medical treatment template actuator also comprises array apparatus down:
The medical record inducting device is used for the coding of the medical record of seeing and treating patients is input to above-mentioned Medical Forms framework, accesses corresponding medical treatment template;
The deletion of items device is used for deleting this project in sign hurdle filling " cancellation ";
Project increases device, and being used for increases new projects in sign hurdle filling " increase " or use enter key;
The project validator is used for confirming this project in sign hurdle filling " plan ";
Project implementation device, be used for after a project implementation, importing actuating code (with) or in sign hurdle filling " execution ";
The signature device is used for above-mentioned list frame content is carried out digital signature respectively by its maker or executor;
The electronic health record compositor is used for above-mentioned executed list as content, and gauge outfit information is as index, the medical institutions' code of seeing and treating patients of Lian Jieing successively, and time code, serial number generate when time electronic health record as sequence number.
7. the medical procedure control method is characterized in that comprising the following steps:
Step 1: by medical treatment day or the inferior medical path list framework of setting up;
Step 2: for the multi-layer information item in the above-mentioned list framework is provided with the sign hurdle;
Step 3: in the list framework, import the medical treatment template project by sick the kind;
Step 4: give the digital signature affirmation after carrying out or adjust template item, and the medical treatment template information after carrying out is pressed the synthetic electronic health record of specified format.
8. method as claimed in claim 7 is characterized in that above-mentioned steps 1 comprises the following steps:
For the Medical Forms framework is set up gauge outfit block of information and Biao Li block of information;
For setting up sick diagnosis, patient's identity, the diagnosis information hurdle of planting in above-mentioned gauge outfit block of information;
For the foundation of above-mentioned sick kind Information comprises first diagnosis, compound second opinion item of information;
For the foundation of above-mentioned patient's identity information hurdle comprises name, identity document title, passport NO., name of contact person, contact method item of information;
Set up for above-mentioned diagnosis information hurdle comprise the number of registering, the source of being in hospital, way of paying, the section office of being in hospital, the number information item of being in hospital;
For setting up management, diagnosis, inspection, material, nursing, treatment, the state that makes a variation, leaves hospital, digital signature information hurdle in block of information in the above-mentioned table;
For setting up doctor, the nurse item of signing in above-mentioned digital signature information hurdle.
9. method as claimed in claim 7 is characterized in that described step 2 comprises the following steps:
To setting up the menu selectionbar by predetermined item of information;
To setting up the hurdle, space by predetermined item of information;
The sign hurdle that above-mentioned item of information setting is comprised plan, cancellation, execution, increase.
10. method as claimed in claim 7 is characterized in that described step 3 comprises the following steps:
Disease kind or its combination are encoded;
According to prior art medical scheme is formulated in disease kind or its combination of above-mentioned definition;
Above-mentioned medical scheme is pressed the input of Medical Forms form.
11. method as claimed in claim 7 is characterized in that described step 4 comprises the following steps:
The coding of the medical record of seeing and treating patients is input in the above-mentioned Medical Forms framework, accesses corresponding medical treatment template;
Delete this project in sign hurdle filling " cancellation ";
Increase new projects in sign hurdle filling " increase " or use enter key;
Confirm this project in sign hurdle filling " plan ";
After a project implementation, import actuating code or identifying hurdle filling " execution ";
Above-mentioned list frame content is carried out digital signature respectively by its maker or executor;
As content, gauge outfit information is as index above-mentioned executed list, the medical institutions' code of seeing and treating patients of Lian Jieing successively, and time code, serial number generate when time electronic health record as sequence number.
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| CN2010101191258A CN101908093A (en) | 2010-01-25 | 2010-01-25 | Electronic medical record and method and system for controlling medical process on the basis of same |
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| CN107145713B (en) * | 2017-04-06 | 2020-08-11 | 广州慧扬健康科技有限公司 | Data statistical analysis system for differential diagnosis |
| CN107317806A (en) * | 2017-06-20 | 2017-11-03 | 上海浩霖汇信息科技有限公司 | A kind of electronics license application copy securely generates method and device |
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| CN108399950A (en) * | 2018-02-05 | 2018-08-14 | 褚晓凡 | The artificial intelligence diagnosis of primary headaches and antidiastole system |
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Application publication date: 20101208 |