CN103530513A - Input system for achieving fast input of electronic medical record - Google Patents
Input system for achieving fast input of electronic medical record Download PDFInfo
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- CN103530513A CN103530513A CN201310474481.5A CN201310474481A CN103530513A CN 103530513 A CN103530513 A CN 103530513A CN 201310474481 A CN201310474481 A CN 201310474481A CN 103530513 A CN103530513 A CN 103530513A
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Abstract
The invention discloses an input system for achieving fast input of an electronic medical record. The input system is composed of an input module, a medical term base, a general service word base, a configuration table, an associative algorithm, an output module and an updating module. The system achieves a method for the fast input of the electronic medical record, and is suitable for the fast input of a free text type electronic medical record and a structured electronic medical record. Through the system, fast writing on the free text type electronic medical record or the structured electronic medical record in traditional Chinese medicine clinic can be achieved, traditional Chinese medicine clinic terms from the real world can be applied to the traditional Chinese medicine clinic scientific research in the real world in a normalized mode, and therefore it is guaranteed that in the clinic work, information can be accurately and efficiently collected, and the clinic electronic medical record meeting quality control requirements can be generated.
Description
Technical field
The present invention relates to electronic health record technical field, specifically refer to a kind of input system that realizes the Rapid input of electronic health record.
Background technology
Along with the development of computing machine and Internet technology, most of hospital has realized the electronization of clinical case history.The typing of electronic health record at present is mainly adopted in two ways, i.e. pre-structure case history typing mode and rear structured patient record typing mode.Rear structuring typing mode adopts the mode of natural language to carry out typing conventionally, be applied to the typing of free text type electronic health record, this kind of mode input speed is very fast, but the information obtaining is non-structured, needs data to carry out a large amount of operational processes in the scientific research in later stage; Pre-structure mode is often referred to uses case history template to generate electronic health record, realizes the structuring of electronic health record by case history template before case history typing, is applied to the typing of structured electronic patient record.Structuring typing mode relatively, pre-structure input speed can be slower conventionally, and along with structurized content is more and more, input speed can be more and more slower.Native system is realized a kind of quick input method of electronic health record, is a kind of input system that had not only been applicable to free text type electronic health record but also had been applicable to the Rapid input of structured electronic patient record.
Summary of the invention
The present invention proposes a kind of input system that had not only been applicable to free text type electronic health record but also had been applicable to the Rapid input of structured electronic patient record.Native system determines that by allocation list current is to carry out free text type electronic health record or the typing of structured electronic patient record.By term, associate and Chinese characters in common use inputs both can guarantee the efficiency of inputting to free text type electronic health record standardization typing that again can implementation structure case history traditional Chinese medicine term.Native system is comprised of seven modules: load module, medical terminology storehouse, conventional dictionary, allocation list, association's algorithm, output module, update module.
1, load module: for inputting medical terminology, user carries out the input of medical terminology by the position of keyboard cursor in electronic health record.Similar to general input method demonstration, all candidate item show in batches.First from medical terminology library searching, go out the medical terminology matching with current input Pinyin, by association's algorithm, sort.Secondly from conventional dictionary, search out the everyday words matching with current input Pinyin, all everyday words are all presented at after medical terminology.
2, medical terminology storehouse: for storing the input required term of medical domain and the various attributes of term, for association's input provides basis.Term in medical terminology storehouse is stored in the mode of dictionary tree, to improve retrieval, the input speed of medical terminology.In terminology bank, store the title of term, the classification of the description of term, term, disease kind, the term under the source of term, term occurs whether document section, term are the information such as standard terminology at certain sick occurrence number, term of planting in certain document section;
3, conventional dictionary: storage everyday words and phrase.
4, allocation list: write with XML form, determine current carry out free text type electronic health record or the typing of structured electronic patient record by configuration parameter, store various parameters, for the calculating of association's algorithm simultaneously.Parameter in allocation list comprises:
The affiliated sick kind of case history, the title of data element and the document section under data element.Allocation list is mainly used in distinguishing the type of current typing.If parameter is empty in allocation list, illustrate that current is in the typing of carrying out free text type electronic health record; Otherwise be in the typing of carrying out structured electronic patient record, information that simultaneously can store electrons case history needs in allocation list.Regulation according to the Ministry of Public Health to electronic health record structure, electronic health record is comprised of data element, data group, document section, clinical documentation section.Term all in electronic health record data element partly carry out typing.
5, association's algorithm: according to configuration parameters different in allocation list, the term searching out is calculated to its matching value by association's algorithm, by showing after the descending sequence of matching value.Association's algorithmic formula is as follows:
MatchValue(w)=Freq
ds,dn,s(w)/MAX(Freq(w))+Std(w)+Ctg
d(w) 1.1
Wherein w represents certain term, and MatchValue (w) represents the matching value of term, Freq
ds, dn, s(w)/MAX (Freq (w)) represents the frequency that term w occurs in certain sick ds of kind, certain diagnosis dn, certain document section s;
6, output module: for searching out the term matching with current input Chinese character or phonetic, user can use mouse or keyboard to select the term that will input as the word that will input.If term to be entered, in candidate prompting, cannot according to system suggestion not carry out typing, with utilize general input method similar, directly carry out the input of Chinese character.
7, update module: after medical record writing, according to new typing from the term in medical terminology storehouse, upgrade the number of times that corresponding term in medical terminology storehouse is sickly planted, occurred in document section at this, for association's algorithm next time, calculate.
The invention has the beneficial effects as follows, by this system, can realize the rapid writing to the free text type electronic health record of tcm clinical practice or structured electronic patient record, can make to standardize and be applied in the work of real world clinical research from real world clinical terms of Traditional Chinese Medicine, thereby both Information Monitorings accurately and efficiently in guarantee clinical position, can generate again the clinical electronic health record that meets Quality Control requirement.
Accompanying drawing explanation
Fig. 1 is system flowchart of the present invention.
Embodiment
The symptom in main suit in typing structuring diabetes case history of take is example.
(1), in example, be to carry out typing in structuring diabetes case history, therefore allocation list content is not empty.The allocation list of writing with XML language is as follows.
(2) if current need to be in main suit typing symptom " left upper extremity pain ", and term exists in medical terminology storehouse.In certain data element of main suit, first utilize load module typing " left upper extremity ", according to each parameter in allocation list and association's algorithm, calculate, front 5 candidate item are " left upper extremity pain ", " left upper extremity is numb ", " left upper extremity is ached ", " left upper extremity contraction pain ", " left upper extremity shouting pain ".Utilize load module to show all candidate item, and front 5 candidate item are shown at first.
If a) current candidate item comprises the term of wanting typing, can by mouse-click or the upper and lower key of keyboard and enter key is selected " in left upper extremity pain ”， main suit, show.After typing, by update module, upgrade " left upper extremity pain " in medical terminology storehouse and appear at the number of times in diabetes case history main suit.
B), if do not comprise the term of wanting typing in the candidate item of current demonstration, by mouse or keyboard Backwards selection, show candidate item below, until there is the candidate item that comprises term to be entered.Again by mouse-click or the upper and lower key of keyboard and enter key is selected " shows in left upper extremity pain ”， main suit.After typing, by update module, upgrade " left upper extremity pain " in medical terminology storehouse and appear at the number of times in diabetes case history main suit.
(3) if current need to be in main suit typing symptom " left upper extremity swelling ", and term does not exist in medical terminology storehouse.In certain data element of main suit, first utilize load module typing " left upper extremity ", according to each parameter in allocation list and association's algorithm, calculate, front 5 candidate item are " left upper extremity pain ", " left upper extremity is numb ", " left upper extremity is ached ", " left upper extremity contraction pain ", " left upper extremity shouting pain ".Utilize load module to show all candidate item, and front 5 candidate item are shown at first.Due to current, treat that typing term does not exist in medical terminology storehouse, through association's algorithm, calculate, in the candidate item of load module prompting, also there is no " left upper extremity swelling ", directly utilize load module, carry out the input of " swelling ".Because this term is not in terminology bank, therefore never call update module.
Claims (8)
1. an input system that realizes electronic health record Rapid input, is characterized in that, this input system is comprised of load module, medical terminology storehouse, conventional dictionary, allocation list, association's algorithm, output module, update module seven parts:
(1) load module: for inputting medical terminology, user carries out the input of medical terminology by the position of keyboard cursor in electronic health record;
(2) medical terminology storehouse: for storing the required medical domain term of input and the various attributes of term, for association's input provides basis;
(3) conventional dictionary: storage everyday words and phrase;
(4) allocation list: determine current carry out free text type electronic health record or the typing of structured electronic patient record by configuration parameter, store various parameters, for the calculating of association's algorithm simultaneously;
(5) association's algorithm: according to configuration parameters different in allocation list, the term searching out is calculated to its matching value by association's algorithm, by showing after the descending sequence of matching value;
(6) output module: for searching out the term matching with current input Chinese character or phonetic, user can use mouse or keyboard to select the term that will input as the word that will input; If term to be entered is not in candidate character, system cannot be pointed out, and the term of input is consistent with the Chinese character that utilizes general input method to input;
(7) update module: after medical record writing, according to new typing from the term in medical terminology storehouse, upgrade the number of times that corresponding term in medical terminology storehouse is sickly planted, occurred in document section at this, for association's algorithm next time, calculate.
2. a kind of input system that realizes electronic health record Rapid input according to claim 1, it is characterized in that, first this input system by load module, goes out the medical terminology matching with current input Pinyin from medical terminology library searching, by association's algorithm, sort; Secondly from conventional dictionary, search out the everyday words matching with current input Pinyin; Finally all everyday words are arranged and are presented at after medical terminology.
3. a kind of input system that realizes electronic health record Rapid input according to claim 1, is characterized in that, the term in medical terminology storehouse is stored in the mode of dictionary tree.
4. a kind of input system that realizes electronic health record Rapid input according to claim 1, it is characterized in that, disease kind, the term under the title of medical terminology library storage term, the description of term, the source of the classification of term, term, term occurs whether document section, term are the information such as standard terminology at certain sick occurrence number, term of planting in certain document section.
5. a kind of input system that realizes electronic health record Rapid input according to claim 1, is characterized in that, allocation list is write with XML form.
6. a kind of input system that realizes electronic health record Rapid input according to claim 1, is characterized in that, the parameter in allocation list comprises: the affiliated sick kind of case history, the title of data element and the document section under data element.
7. a kind of input system that realizes electronic health record Rapid input according to claim 1, is characterized in that, can distinguish the type of current typing by allocation list:
If parameter is empty in allocation list, current is the typing of free text type electronic health record; Otherwise be structured electronic patient record typing.
8. a kind of input system that realizes electronic health record Rapid input according to claim 1, is characterized in that, association's algorithmic formula is:
MatchValue(w)＝Freq
ds,dn,s(w)/MAX(Freq(w))+Std(w)+Ctg
d(w)
Wherein w represents certain term, and MatchValue (w) represents the matching value of term, Freq
ds, dn, s(w)/MAX (Freq (w)) represents the frequency that term w occurs in certain sick ds of kind, certain diagnosis dn, certain document section s.
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| CN108170677A (en) * | 2017-12-27 | 2018-06-15 | 北京嘉和美康信息技术有限公司 | A kind of medical terms abstracting method and device |
| CN109710670A (en) * | 2018-12-11 | 2019-05-03 | 河南通域医疗科技有限公司 | A method of case history text is converted into structural metadata from natural language |
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