CN102346814A - Entering method of tabular fragment structured EMR (Electronic Medical Record) - Google Patents
Entering method of tabular fragment structured EMR (Electronic Medical Record) Download PDFInfo
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- CN102346814A CN102346814A CN2011103432412A CN201110343241A CN102346814A CN 102346814 A CN102346814 A CN 102346814A CN 2011103432412 A CN2011103432412 A CN 2011103432412A CN 201110343241 A CN201110343241 A CN 201110343241A CN 102346814 A CN102346814 A CN 102346814A
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Abstract
The invention relates to the filed of medical treatment, in particular to an implementation method of an EMR (Electronic Medical Record), which belongs to the large class of G06F19/00 in the international patent classification (IPC) table. The invention provides an entering method of a tabular fragment structured EMR, which comprises the following steps of: converting the medical record content with a logic structure into a complete structured tabular mode; entering the medical record content by selecting the attribute values of key points so as to form standardized diagnosis data; entering the tabular fragment diagnosis and treatment information generated by the key values and the attribute values of the key points; and finally, automatically generating a free text type medical record by a system so that the problem that a medical record fragment with strong logic expression can not be quickly entered can be solved. According to the invention, the medical record fragment with the strong logic expression is quickly entered, and thus, the acquisition of the medical treatment information data in the large range is realized.
Description
Technical field
The present invention relates to medical field, particularly relate to the implementation method of electronic health record, in International Patent Classification (IPC) IPC, can belong to big group of G06F19/00.
Background technology
Electronic health record is that modern medical service mechanism carries out efficiently, the clinic diagnosis of high-quality, scientific research and the necessary important clinical information resources of medical control work, also is the main information source of residents ' health archives.The standardized electronic case history and with its be the hospital information system construction of new generation of core be realize clinical information that regional extent is served as theme with resident individual share with medical institutions interconnect, the prerequisite basis of cooperation with service; Can not only guarantee residents ' health archives " that number goes out is active, number go out to have according to "; Can also help to implement, the standard clinical path; The supervision of realization medical procedure improves medical treatment level and emergency command ability.
Be used for clinical electronic health record at present and mainly support free text typing, typing template and key word are characteristic, are to adopt this pattern in full.But in existing electronic health record typing mode; When running into when the case history content with logical organization is converted into the case history of structuring forms mode; Though adopt the electronic health record of this this pattern of full text clearly to express logical relation, satisfy application demand, input speed is slow; Can't satisfy the application scenario of typing fast in enormous quantities, and its standardization is poor.
Summary of the invention
Deficiency to prior art; The invention provides a kind of input method of sheet format fragment structure electronic health record; The case history content that employing will have logical organization is converted into structuring forms mode completely; Carry out typing through the property value of selecting each key point and form standardized diagnosis and treatment data; Typing solves the strong case history fragment of the logical expression problem of typing fast through the sheet format fragment diagnosis and treatment information of key value and property value series connection generation thereof thereby final system generates free text type case history automatically again.
For achieving the above object, the present invention realizes through following technical scheme: a kind of input method of sheet format fragment structure electronic health record may further comprise the steps:
Make up key value and attribute list thereof, its form is a standard format, and being used for typing can standardized diagnosis and treatment data;
Make up sheet format fragment text, its form is a free-format, is used for the sheet format fragment diagnosis and treatment information that typing generates through key value and property value series connection thereof;
Make up free text type case history, it is constituted by the robotization of said sheet format fragment text, is used for the typing diagnosis and therapy recording.
Further, described keyword and property value thereof are medical treatment or the diagnosis terms that basis and the movable information of electronic health record related service write down the standard of extracting.
Further, described method also comprises:
Keyword attribute tabulation design procedure is used to accept the self-defined of user, with the attribute structure body of structure tree structure or at least one property value in the delete property structure.
Further, described method also comprises:
Sheet format fragment structure design procedure is used to accept the self-defined of user, expresses diagnosis and treatment information to make up structured logic.
Further, making up case history also comprises:
The visual edit manager is provided, is used to receive the user,, thereby realize that the user successively edits the content of diagnosis and treatment data, diagnosis and treatment information and diagnosis and therapy recording typing, the modification of property value for the relevant keyword of said case history and the selection of property value thereof.
The beneficial effect that the present invention has is: realized solving the strong quick typing of case history fragment of logical expression; And flexible typing demand that can be satisfying personalized can realize the collection of large-scale medical information data, and adopts visual edit, and is simple to operation.
Description of drawings
Fig. 1 is the process flow diagram of input method of the sheet format fragment structure electronic health record of the embodiment of the invention.
Embodiment
Combine accompanying drawing and embodiment that the present invention is further specified at present.
With reference to shown in Figure 1, the flow process of the input method of sheet format fragment structure electronic health record may further comprise the steps:
Step S10 makes up key value and attribute list thereof, and its form is a standard format, and being used for typing can standardized diagnosis and treatment data;
Further, described keyword and property value thereof are medical treatment or the diagnosis terms that basis and the movable information of electronic health record related service write down the standard of extracting.
Step S20 makes up sheet format fragment text, and its form is a free-format, is used for the sheet format fragment diagnosis and treatment information that typing generates through key value and property value series connection thereof;
Step S30 makes up free text type case history, and it is constituted by the robotization of said sheet format fragment text, is used for the typing diagnosis and therapy recording.
Also comprise in the described method S10 step:
Step S11, keyword attribute tabulation design procedure is used to accept the self-defined of user, with the attribute structure body of structure tree structure or at least one property value in the delete property structure.
Also comprise in the described method S20 step:
Step S21, sheet format fragment structure design procedure is used to accept the self-defined of user, expresses diagnosis and treatment information to make up structured logic.
Further, making up case history also comprises:
The visual edit manager is provided, is used to receive the user,, thereby realize that the user successively edits the content of diagnosis and treatment data, diagnosis and treatment information and diagnosis and therapy recording typing, the modification of property value for the relevant keyword of said case history and the selection of property value thereof.
The beneficial effect that the present invention has is: realized solving the strong quick typing of case history fragment of logical expression; And flexible typing demand that can be satisfying personalized can realize the collection of large-scale medical information data, and adopts visual edit, and is simple to operation.
Although specifically show and introduced the present invention in conjunction with preferred embodiment; But the those skilled in the art should be understood that; In the spirit and scope of the present invention that do not break away from appended claims and limited; Can make various variations to the present invention in form with on the details, be protection scope of the present invention.
Claims (5)
1. the input method of sheet format fragment structure electronic health record is characterized in that, may further comprise the steps:
Make up key value and attribute list thereof, its form is a standard format, and being used for typing can standardized diagnosis and treatment data;
Make up sheet format fragment text, its form is a free-format, is used for the sheet format fragment diagnosis and treatment information that typing generates through key value and property value series connection thereof;
Make up free text type case history, it is constituted by the robotization of said sheet format fragment text, is used for the typing diagnosis and therapy recording.
2. the input method of sheet format fragment structure electronic health record according to claim 1 is characterized in that, described keyword and property value thereof are medical treatment or the diagnosis terms that basis and the movable information of electronic health record related service write down the standard of extracting.
3. the input method of sheet format fragment structure electronic health record according to claim 1 is characterized in that, also comprises:
Keyword attribute tabulation design procedure is used to accept the self-defined of user, with the attribute structure body of structure tree structure or at least one property value in the delete property structure.
4. the input method of sheet format fragment structure electronic health record according to claim 1 is characterized in that, also comprises:
Sheet format fragment structure design procedure is used to accept the self-defined of user, expresses diagnosis and treatment information to make up structured logic.
5. the input method of sheet format fragment structure electronic health record according to claim 1 is characterized in that, makes up case history and also comprises:
The visual edit manager is provided, is used to receive the user,, thereby realize that the user successively edits the content of diagnosis and treatment data, diagnosis and treatment information and diagnosis and therapy recording typing, the modification of property value for the relevant keyword of said case history and the selection of property value thereof.
Priority Applications (1)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CN2011103432412A CN102346814A (en) | 2011-11-03 | 2011-11-03 | Entering method of tabular fragment structured EMR (Electronic Medical Record) |
Applications Claiming Priority (1)
| Application Number | Priority Date | Filing Date | Title |
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| CN2011103432412A CN102346814A (en) | 2011-11-03 | 2011-11-03 | Entering method of tabular fragment structured EMR (Electronic Medical Record) |
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| CN102346814A true CN102346814A (en) | 2012-02-08 |
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| CN2011103432412A Pending CN102346814A (en) | 2011-11-03 | 2011-11-03 | Entering method of tabular fragment structured EMR (Electronic Medical Record) |
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Cited By (3)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN104050615A (en) * | 2014-07-10 | 2014-09-17 | 首都医科大学附属北京佑安医院 | System for generating structured electronic medical record |
| CN106503424A (en) * | 2016-09-30 | 2017-03-15 | 广州慧扬信息系统科技有限公司 | A kind of learning-oriented electronic health record input method |
| CN114912887A (en) * | 2022-04-20 | 2022-08-16 | 深圳市医未医疗科技有限公司 | Clinical data entry method and device based on electronic medical record |
Citations (3)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN101236579A (en) * | 2008-02-20 | 2008-08-06 | 杭州创业软件股份有限公司 | Dynamic structured electronic patient history |
| CN101908093A (en) * | 2010-01-25 | 2010-12-08 | 田小平 | Electronic medical record and method and system for controlling medical process on the basis of same |
| CN102122312A (en) * | 2010-01-11 | 2011-07-13 | 新阳电脑科技股份有限公司 | Electronic medical record generating method for adjunct modification-free medical information system |
-
2011
- 2011-11-03 CN CN2011103432412A patent/CN102346814A/en active Pending
Patent Citations (3)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN101236579A (en) * | 2008-02-20 | 2008-08-06 | 杭州创业软件股份有限公司 | Dynamic structured electronic patient history |
| CN102122312A (en) * | 2010-01-11 | 2011-07-13 | 新阳电脑科技股份有限公司 | Electronic medical record generating method for adjunct modification-free medical information system |
| CN101908093A (en) * | 2010-01-25 | 2010-12-08 | 田小平 | Electronic medical record and method and system for controlling medical process on the basis of same |
Cited By (4)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN104050615A (en) * | 2014-07-10 | 2014-09-17 | 首都医科大学附属北京佑安医院 | System for generating structured electronic medical record |
| CN106503424A (en) * | 2016-09-30 | 2017-03-15 | 广州慧扬信息系统科技有限公司 | A kind of learning-oriented electronic health record input method |
| CN106503424B (en) * | 2016-09-30 | 2019-04-23 | 广州慧扬信息系统科技有限公司 | A kind of learning-oriented electronic health record input method |
| CN114912887A (en) * | 2022-04-20 | 2022-08-16 | 深圳市医未医疗科技有限公司 | Clinical data entry method and device based on electronic medical record |
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Application publication date: 20120208 |