CN104050393A - Progress note self-inspection system and method - Google Patents
Progress note self-inspection system and method Download PDFInfo
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- CN104050393A CN104050393A CN201410326891.XA CN201410326891A CN104050393A CN 104050393 A CN104050393 A CN 104050393A CN 201410326891 A CN201410326891 A CN 201410326891A CN 104050393 A CN104050393 A CN 104050393A
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Abstract
The invention relates to a progress note self-inspection system and method. The progress note self-inspection system comprises a symptom and sign dictionary module, a variation trend module, a doctor medical history writing module and a logic verification module. The variation trend module is both connected with the symptom and sign dictionary module and the doctor medical history writing module, and the doctor medical history writing module is connected with the logic verification module. The self-inspection method for realizing the progress note self-inspection system includes the following steps that (1) all progress notes of a patient in hospital at this time are taken out through a hospital code of the patient; (2) the progress notes are sorted according to the writing time sequence of the progress notes; (3) all symptoms and signs in a latest course of a disease under the course of the disease are extracted, when the symptoms and signs are vanished or removed, the symptoms and signs are removed, and conversely the symptoms and signs are initialized into the next progress note. By means of the self-inspection system and method, the correctness of the progress notes can be guaranteed.
Description
Technical field
The invention belongs to software field, be specifically related to a kind of self-checking system and self checking method of progress note.
Background technology
Progress note refers to after RAN, the continuity record that conditions of patients and diagnosis and treatment process are carried out, content comprises that make the rounds of the wards suggestion, consultation of doctors suggestion, doctor of patient's change of illness state situation, important auxiliary examination result and clinical meaning, higher level doctor analyze the material particular of suggestion, the diagnosis and treatment measure of taking and effect, doctor's advice change and reason being discussed, inform to patient and close relative thereof etc.
But in actual operation, due to doctor's level and careful and responsible degree very different, minority doctor can not write progress note completely according to the rules, causes the progress note that doctor writes can not reflect completely really patient's Hospitalization situation.
Summary of the invention
Goal of the invention: the problem that the present invention is directed to above-mentioned prior art existence makes improvements, be that the technical matters that the present invention solves is the nonstandard problem of progress note, first object of the present invention is to provide a kind of self-checking system of progress note, and second object of the present invention is to provide a kind of self checking method of progress note.
Technical scheme: a kind of self-checking system of progress note, the self-checking system of described progress note belongs to structured electronic patient record, the self-checking system of described progress note comprises that symptom and sign dictionary module, variation tendency module, doctor write case history module and logic checking module, described variation tendency module is write case history module with described symptom and sign dictionary module, described doctor respectively and is connected, and described doctor writes case history module and is connected with described logic checking module.
A kind of preferred version as the self-checking system of the progress note in the present invention: the structuring in described symptom and sign dictionary module selects element to adopt the medical terminology in Chinese edition clinical medical term standard SNOMED CT.
A kind of preferred version as the self-checking system of the progress note in the present invention: the structuring in described variation tendency module selects element to adopt the medical terminology in Chinese edition clinical medical term standard SNOMED CT.
A kind of preferred version as the self-checking system of the progress note in the present invention: the structuring that described doctor writes in case history module selects element to adopt the medical terminology in Chinese edition clinical medical term standard SNOMED CT.
A self checking method of realizing the self-checking system of above-mentioned progress note, comprises the steps:
(1), take out by patient's the coding of being in hospital all progress notes that patient is this time in hospital;
(2), taking the time order and function of writing progress note as order, progress note described in step (1) is sorted;
(3), extract the symptom and sign under all these progress notes in nearest a progress note, when described symptom and sign is for disappearing or when normal, removing described symptom and sign; Otherwise, described symptom and sign is initialised in lower a progress note.
A kind of preferred version as self checking method in the present invention: in the time that described symptom and sign is newly-increased symptom and sign, the title of described newly-increased symptom and sign, the description of described newly-increased symptom and sign can be modified and delete.
A kind of preferred version as self checking method in the present invention: the state of the symptom and sign in each progress note is if not " normally " or " disappearance ", and this symptom and sign will be increased in next progress note automatically; Otherwise this illness sign will there will not be in next progress note.
A kind of preferred version as self checking method in the present invention: print before case history at every turn, all will, by be this time the in hospital logicality of evolving trend of all symptom and signs of all progress notes of described logic checking module verification patient, comprise the following steps:
(1), take out by patient's the coding of being in hospital all progress notes that patient is this time in hospital;
(2), according to the writing time sequence of the described all progress notes of step (1);
(3), take out first progress note in step (2), preserve all newly-increased symptom and sign under described first progress note by array, all symptom and signs under Article 2 progress note in all newly-increased symptom and sign under described first progress note and step (2) are compared, when symptom and sign normal or that disappear in the time that the newly-increased symptom and sign in described first progress note is all non-newly-increased record in described Article 2 progress note and in described first progress note does not occur in Article 2 progress note, judge that described Article 2 progress note is qualified, otherwise, judge that described Article 2 progress note is defective, by that analogy, judge successively the logicality of all progress notes, to the last till a progress note.
Beneficial effect: the self-checking system of a kind of progress note provided by the invention and method thereof, have following beneficial effect:
1, systematically record and evaluate the clinical data such as positive symptom, sign, more intactly save data;
2, be convenient to add up the information such as symptom, sign in magnanimity medical history information, for the summary of clinical case history data and the excavation of scientific research data lay the foundation;
3, every day, infusion treatment list can provide each intravenous administration to observe at 12 interior monitoring contents to infusion-completed and bad reaction from opening doctor's advice in detail;
4, retain the feature of traditional progress note, be convenient to clinician's physical record and analysing patient's condition;
5, in system Automatically invoked NN, data generate nursing abridged table, and the data such as vital sign are very clear;
6, provide quick look facility: conveniently check temperature chart, NN list, every day infusion treatment list;
7, guarantee the correctness of progress note, ensured the illness sign record of every sufferer to carry it through to the end.
Brief description of the drawings
Fig. 1 is the structural representation of the self-checking system of progress note provided by the invention
Fig. 2 is the process flow diagram of the self checking method of progress note provided by the invention
Embodiment:
Below in conjunction with accompanying drawing, the specific embodiment of the present invention is described in detail.
As shown in Figure 1, a kind of self-checking system of progress note, the self-checking system of progress note belongs to structured electronic patient record, the self-checking system of progress note comprises that symptom and sign dictionary module, variation tendency module, doctor write case history module and logic checking module, variation tendency module is write case history module with symptom and sign dictionary module, doctor respectively and is connected, and doctor writes case history module and is connected with logic checking module.Doctor clicks symptom and sign dictionary module, variation tendency module and doctor and writes the selection element in case history module, thereby forms patient's progress note; Logic checking module can be carried out logic judgement to the adjacent progress note of same patient.
Structuring in a kind of symptom and sign dictionary module of self-checking system of progress note selects element to adopt the medical terminology in Chinese edition clinical medical term standard SNOMED CT.Symptom and sign dictionary module belongs to structured electronic patient record.Progress note comprises first progress note, daily progress note, the record of handing over to the next shift, the record of succeeding, produces record, proceeds to record, record, operation note, rescue record are made the rounds of the wards in stage brief summary, postoperative progress note first, higher level.
Structuring in a kind of variation tendency module of self-checking system of progress note selects element to adopt the medical terminology in Chinese edition clinical medical term standard SNOMED CT.Variation tendency module provides symptom and sign dictionary trend to select, variation tendency comprise increase the weight of, as before, take a turn for the better, disappear, normal, mismatch, other and newly-increased (occur separately, do not want drop-down selection).
The structuring that a kind of doctor of self-checking system of progress note writes in case history module selects element to adopt the medical terminology in Chinese edition clinical medical term standard SNOMED CT.Doctor writes case history module and belongs to structured electronic patient record.
As shown in Figure 2, a kind of self checking method of the self-checking system that realizes above-mentioned progress note, comprises the steps:
(1), take out by patient's the coding of being in hospital all progress notes that patient is this time in hospital;
(2), sort taking time order and function progress note in ordered pair step (1) of writing progress note;
(3), extract the symptom and sign under all these progress notes in nearest a progress note, when symptom and sign is for disappearing or when normal, removing symptom and sign; Otherwise, symptom and sign is initialised in lower a progress note.
In a kind of self checking method of the self-checking system that realizes above-mentioned progress note, in the time that symptom and sign is newly-increased symptom and sign, the description of the title of newly-increased symptom and sign, newly-increased symptom and sign can be modified and delete.
In a kind of self checking method of the self-checking system that realizes above-mentioned progress note, the state of the symptom and sign in each progress note is if not " normally " or " disappearance ", and this symptom and sign will be increased in next progress note automatically; Otherwise this illness sign will there will not be in next progress note.
In a kind of self checking method of the self-checking system that realizes above-mentioned progress note, print before case history at every turn, all will, by be this time the in hospital logicality of evolving trend of all symptom and signs of all progress notes of logic checking module verification patient, comprise the following steps:
(1), take out by patient's the coding of being in hospital all progress notes that patient is this time in hospital;
(2), according to the writing time sequence of all progress notes of step (1);
(3), take out first progress note in step (2), preserve all newly-increased symptom and sign under first progress note by array, all symptom and signs under Article 2 progress note in all newly-increased symptom and sign under first progress note and step (2) are compared, when symptom and sign normal or that disappear in the time that the newly-increased symptom and sign in first progress note is all non-newly-increased record in Article 2 progress note and in first progress note does not occur in Article 2 progress note, judge that Article 2 progress note is qualified, otherwise, judge that Article 2 progress note is defective, by that analogy, judge successively the logicality of all progress notes, to the last till a progress note.
Only have by logic checking module verification patient to be this time in hospital after the logicality of symptom and sign evolving trend in all progress notes, could print case history.
By reference to the accompanying drawings embodiments of the present invention are described in detail above.But the present invention is not limited to above-mentioned embodiment, in the ken possessing at affiliated technical field those of ordinary skill, can also under the prerequisite that does not depart from aim of the present invention, make a variety of changes.
Claims (7)
1. the self-checking system of a progress note, it is characterized in that, the self-checking system of described progress note belongs to structured electronic patient record, the self-checking system of described progress note comprises that symptom and sign dictionary module, variation tendency module, doctor write case history module and logic checking module, described variation tendency module is write case history module with described symptom and sign dictionary module, described doctor respectively and is connected, and described doctor writes case history module and is connected with described logic checking module.
2. the self-checking system of a kind of progress note as claimed in claim 1, is characterized in that, the structuring in described symptom and sign dictionary module selects element to adopt the medical terminology in Chinese edition clinical medical term standard SNOMED CT.
3. the self-checking system of a kind of progress note as claimed in claim 1, is characterized in that, the structuring in described variation tendency module selects element to adopt the medical terminology in Chinese edition clinical medical term standard SNOMED CT.
4. the self-checking system of a kind of progress note as claimed in claim 1, is characterized in that, the structuring that described doctor writes in case history module selects element to adopt the medical terminology in Chinese edition clinical medical term standard SNOMED CT.
5. a self checking method of realizing the self-checking system of progress note described in claim 1～4, comprises the steps:
(1), take out by patient's the coding of being in hospital all progress notes that patient is this time in hospital;
(2), taking the time order and function of writing progress note as order, progress note described in step (1) is sorted;
(3), extract the symptom and sign under all these progress notes in nearest a progress note, when described symptom and sign is for disappearing or when normal, removing described symptom and sign; Otherwise, described symptom and sign is initialised in lower a progress note.
6. self checking method as claimed in claim 5, is characterized in that, in the time that described symptom and sign is newly-increased symptom and sign, the title of described newly-increased symptom and sign, the description of described newly-increased symptom and sign can be modified and delete.
7. self checking method as claimed in claim 5, is characterized in that, prints before case history at every turn, all will, by be this time the in hospital logicality of evolving trend of all symptom and signs of all progress notes of described logic checking module verification patient, comprise the following steps:
(1), take out by patient's the coding of being in hospital all progress notes that patient is this time in hospital;
(2), according to the writing time sequence of the described all progress notes of step (1);
(3), take out first progress note in step (2), preserve all newly-increased symptom and sign under described first progress note by array, all symptom and signs under Article 2 progress note in all newly-increased symptom and sign under described first progress note and step (2) are compared, when symptom and sign normal or that disappear in the time that the newly-increased symptom and sign in described first progress note is all non-newly-increased record in described Article 2 progress note and in described first progress note does not occur in Article 2 progress note, judge that described Article 2 progress note is qualified, otherwise judge that described Article 2 progress note is defective, by that analogy, judge successively the logicality of all progress notes, to the last till a progress note.
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Cited By (3)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN105786934A (en) * | 2014-12-26 | 2016-07-20 | 北大医疗信息技术有限公司 | Method and system for processing medical record document |
| CN107545023A (en) * | 2017-05-11 | 2018-01-05 | 新华三大数据技术有限公司 | The extracting method and device of text-type index |
| CN111430037A (en) * | 2020-03-30 | 2020-07-17 | 安徽科大讯飞医疗信息技术有限公司 | Similar medical record searching method and system |
Citations (4)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN101034410A (en) * | 2007-04-16 | 2007-09-12 | 浙江大学 | Medical treatment case index cast and electronic medical record system based on same |
| 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 |
| US20130103423A1 (en) * | 2010-03-04 | 2013-04-25 | Kwan Hyoung Kim | Cooperative medical consultation and diagnosis system and a method therefor |
| CN103617343A (en) * | 2013-11-06 | 2014-03-05 | 中国人民解放军第四军医大学 | Emergency treatment electronic medical record system and information processing method thereof |
-
2014
- 2014-07-10 CN CN201410326891.XA patent/CN104050393B/en not_active Expired - Fee Related
Patent Citations (4)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN101034410A (en) * | 2007-04-16 | 2007-09-12 | 浙江大学 | Medical treatment case index cast and electronic medical record system based on same |
| 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 |
| US20130103423A1 (en) * | 2010-03-04 | 2013-04-25 | Kwan Hyoung Kim | Cooperative medical consultation and diagnosis system and a method therefor |
| CN103617343A (en) * | 2013-11-06 | 2014-03-05 | 中国人民解放军第四军医大学 | Emergency treatment electronic medical record system and information processing method thereof |
Non-Patent Citations (2)
| Title |
|---|
| 倪青 等: "糖尿病中医结构化住院病历信息采集系统构建与应用", 《中国数字医学》 * |
| 邱杰 等: "对电子病历系统全程质控管理的探讨", 《中国数字医学》 * |
Cited By (6)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN105786934A (en) * | 2014-12-26 | 2016-07-20 | 北大医疗信息技术有限公司 | Method and system for processing medical record document |
| CN105786934B (en) * | 2014-12-26 | 2020-06-12 | 北大医疗信息技术有限公司 | Medical record document defect processing method and system |
| CN107545023A (en) * | 2017-05-11 | 2018-01-05 | 新华三大数据技术有限公司 | The extracting method and device of text-type index |
| CN107545023B (en) * | 2017-05-11 | 2020-03-06 | 新华三大数据技术有限公司 | Method and device for extracting text type indexes |
| CN111430037A (en) * | 2020-03-30 | 2020-07-17 | 安徽科大讯飞医疗信息技术有限公司 | Similar medical record searching method and system |
| CN111430037B (en) * | 2020-03-30 | 2024-04-09 | 讯飞医疗科技股份有限公司 | Similar medical record searching method and system |
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| CN104050393B (en) | 2018-01-05 |
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