CN104240171A - Method and system for generating electronic medical records - Google Patents
Method and system for generating electronic medical records Download PDFInfo
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- CN104240171A CN104240171A CN201410527973.0A CN201410527973A CN104240171A CN 104240171 A CN104240171 A CN 104240171A CN 201410527973 A CN201410527973 A CN 201410527973A CN 104240171 A CN104240171 A CN 104240171A
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Abstract
An embodiment of the invention discloses a method and a system for generating electronic medical records. The method includes dividing information of medical records into a plurality of portions, and determining electronic medical record basic templates according to identification information of identities of patients and identification information of therapeutic schemes in electronic medical record generating procedures; determining identification information of therapeutic steps according to selection instructions; receiving inputted text information corresponding to information of j<th> identification marks when the identification information of each therapeutic step is determined; adding the received text information corresponding to the information of the j<th> identification marks into text adding regions in the electronic medical record basic templates according to preset sequences of the identification information of the therapeutic steps when electronic medical record generating instructions are generated, and generating the electronic medical records. The electronic medical record basic templates contain the information of the identification marks of the various portions of the information of the medical records. The text adding regions correspond to the information of the j<th> identification marks. The method and the system have the advantage that electronic medical record checking or editing operation can be simplified for medical staffs by the aid of the method and the system.
Description
Technical field
The present invention relates to electronic information technical field, more particularly, relate to a kind of electronic health record and generate method and system.
Background technology
Case history is medical worker to the generation of patient disease, develops, lapses to, and patient checked, diagnose, the record of the curative activity process such as treatment.The data collected is concluded, is arranged, comprehensively analyzed, the patient medical health account write by form and the requirement of regulation.Important effect is had to medical treatment, prevention, teaching, scientific research, hospital management etc.
Along with the development of electronic information technology, electronic health record is more and more applied in curative activity process.But current electronic health record only provides the electronic health record template for certain medical rings in curative activity process, in electronic health record template, input medical data by the medical worker of each medical rings and generate the final electronic health record for this medical rings.
And due to the electronic health record of each medical rings separate, therefore, when medical worker needs to view or edit medical record information, need to open different electronic health records, make the operation of medical worker more loaded down with trivial details.Therefore, how to simplify the operation that medical worker views or edits electronic health record and become problem demanding prompt solution.
Summary of the invention
The object of the application is to provide a kind of electronic health record and generates method and system, to simplify the operation that medical worker views or edits electronic health record.
For achieving the above object, the invention provides following technical scheme:
A kind of electronic health record generation method, be applied to electronic equipment, medical record information is divided into some parts, described method comprises:
According to selection instruction determination template attributes information, described template attributes information comprises: the identifying information of patient identity identifying information and therapeutic scheme;
Load the electronic health record foundation forms corresponding with described template attributes information, described electronic health record foundation forms comprises the identification marking information of each several part medical record information; Wherein, the identifying information of identifying information at least one therapeutic progresses corresponding of described therapeutic scheme, several identification marking information in the corresponding described electronic health record foundation forms of identifying information of each therapeutic progresses;
According to the identifying information of selection instruction determination therapeutic progresses;
After often determining the identifying information of a therapeutic progresses, receive input with a jth text message that identification marking information is corresponding;
When there being electronic health record to generate instruction generation, be added in described electronic health record foundation forms with described jth identification marking information corresponding text Adding Area in by what receive with a jth text message that identification marking information is corresponding according to the order of the identifying information of the therapeutic progresses preset, generate electronic health record.
Said method, preferably, described template attributes information also comprises: diagnostic-type information.
Said method, preferably, described being added in text Adding Area corresponding with a described jth identification marking information in described electronic health record foundation forms according to the order of identifying information of the therapeutic progresses preset with a jth text message that identification marking information is corresponding of receiving to be comprised:
Positional information according to a described jth identification marking information searches a described jth identification marking information in described electronic health record foundation forms;
Determine the text Adding Area corresponding with a described jth identification marking information;
Successively corresponding with each therapeutic progresses is added in determined text Adding Area with a jth text message that identification marking information is corresponding according to the order of the identifying information of the therapeutic progresses preset.
Said method, preferably, after generation electronic health record, also comprises:
When receiving output order, export described electronic health record.
A kind of electronic health record generation system, in electronic equipment, medical record information should be divided into some parts, described system comprises:
First determination module, for foundation selection instruction determination template attributes information, described template attributes information comprises: the identifying information of patient identity identifying information and therapeutic scheme;
Load-on module, for loading the electronic health record foundation forms corresponding with described template attributes information, described electronic health record foundation forms comprises the identification marking information of each several part medical record information; Wherein, the identifying information of identifying information at least one therapeutic progresses corresponding of each therapeutic scheme, identifying information several identification marking information corresponding of each therapeutic progresses;
Second determination module, for the identifying information according to selection instruction determination therapeutic progresses;
Receiver module, for after described second determination module determines the identifying information of an instruction step, receive input with a jth text message that identification marking information is corresponding;
Generation module, for when there being electronic health record to generate instruction generation, be added in described electronic health record foundation forms with described jth identification marking information corresponding text Adding Area in by what receive with a jth text message that identification marking information is corresponding according to the order of the identifying information of the therapeutic progresses preset, generate electronic health record.
Said system, preferably, described template attributes information also comprises: diagnostic-type information.
Said system, preferably, described generation module comprises:
First determining unit, searches a described jth identification marking information for the positional information according to a described jth identification marking information in described electronic health record foundation forms;
Second determining unit, for determining the text Adding Area corresponding with a described jth identification marking information;
Adding device, for being added into corresponding with the identifying information of each therapeutic progresses in determined text Adding Area with a jth text message that identification marking information is corresponding successively according to the order of the therapeutic progresses identification marking information preset.
Said system, preferably, also comprises:
Output control module, for when receiving output order, exports described electronic health record.
Known by above scheme, a kind of electronic health record that the application provides generates method and system, medical record information is divided into some parts, in the process generating electronic health record, according to patient identity identifying information and therapeutic scheme identifying information determination electronic health record foundation forms, electronic health record foundation forms comprises the identification marking information of each several part medical record information, wherein, the identifying information of identifying information at least one therapeutic progresses corresponding of described therapeutic scheme, several identification marking information in the corresponding described electronic health record foundation forms of identifying information of each therapeutic progresses, visible, in the embodiment of the present application, each identification marking information on electronic health record foundation forms is to the identifying information that should have at least one therapeutic progresses, therefore, in the embodiment of the present application, every part medical record information by under different therapeutic progresses to should part text message combine, that is, the electronic health record that the embodiment of the present application provides generates method and system, each several part medical record information is generated by the implementation step piecewise combination of therapeutic scheme, thus the complete electronic health record generated for the whole therapeutic process of patient, when medical record information viewed or edited by needs, medical worker only needs to view or edit an electronic health record, and no longer need to open multiple electronic health record, thus simplify the operation that medical worker views or edits electronic health record.
Accompanying drawing explanation
In order to be illustrated more clearly in the embodiment of the present invention or technical scheme of the prior art, be briefly described to the accompanying drawing used required in embodiment or description of the prior art below, apparently, accompanying drawing in the following describes is only some embodiments of the present invention, for those of ordinary skill in the art, under the prerequisite not paying creative work, other accompanying drawing can also be obtained according to these accompanying drawings.
A kind of realization flow figure of the electronic health record generation method that Fig. 1 provides for the embodiment of the present application;
What Fig. 2 provided for the embodiment of the present application is added into a kind of realization flow figure in electronic health record foundation forms with the position of jth identification marking information corresponding region in a jth text message that identification marking information is corresponding according to the therapeutic progresses order preset by what receive;
A kind of structural representation of the electronic health record generation system that Fig. 3 provides for the embodiment of the present application;
A kind of structural representation of the generation module that Fig. 4 provides for the embodiment of the present application;
The another kind of structural representation of the electronic health record generation system that Fig. 5 provides for the embodiment of the present application.
Term " first ", " second ", " the 3rd " " 4th " etc. (if existence) in instructions and claims and above-mentioned accompanying drawing are for distinguishing similar part, and need not be used for describing specific order or precedence.Should be appreciated that the data used like this can be exchanged in the appropriate case, so that the embodiment of the application described herein can be implemented with the order except illustrated here.
Embodiment
Below in conjunction with the accompanying drawing in the embodiment of the present invention, be clearly and completely described the technical scheme in the embodiment of the present invention, obviously, described embodiment is only the present invention's part embodiment, instead of whole embodiments.Based on the embodiment in the present invention, those of ordinary skill in the art, not making the every other embodiment obtained under creative work prerequisite, belong to the scope of protection of the invention.
The electronic health record generation method that the embodiment of the present application provides is applied to electronic equipment, and this electronic equipment can be computing machine, or is mobile terminal etc.
Refer to Fig. 1, a kind of realization flow figure of the electronic health record generation method that Fig. 1 provides for the embodiment of the present application, can comprise:
Step S11: according to selection instruction determination template attributes information, described template attributes information can comprise: the identifying information of patient identity identifying information and therapeutic scheme;
In the embodiment of the present application, selection instruction by medical worker's clicking trigger, namely can click template attributes information by medical worker.
Wherein, the identifying information of patient identity can refer to the name of patient and/or the numbering of patient;
For different medical subject, can pre-determine this medical section diagnostic result that medical worker often assigns now according to actual conditions has which, and for certain diagnostic result, which the therapeutic scheme that medical worker often selects has again.
In the embodiment of the present application, can monitor for certain diagnostic result information click instruction after, namely after medical worker clicks diagnostic result, display the alternative therapeutic scheme corresponding with this diagnostic result information click for medical worker.
Step S12: load the electronic health record foundation forms corresponding with described template attributes information, described electronic health record foundation forms comprises the identification marking information of each several part medical record information; Wherein, the identifying information of identifying information at least one therapeutic progresses corresponding of described therapeutic scheme, several identification marking information in the corresponding described electronic health record foundation forms of identifying information of each therapeutic progresses;
Electronic health record foundation forms can be prestored, after determining template attributes information, load this electronic health record foundation forms.
In the embodiment of the present application, can based on the therapeutic scheme implementation process of reality, set up the corresponding relation of therapeutic scheme identifying information and therapeutic progresses identifying information in advance, and the corresponding relation of some identification marking information in therapeutic progresses identifying information and electronic health record foundation forms.
After template attributes information has been selected, automatically can load electronic health record foundation forms, also can be triggered loading electronic health record foundation forms by medical worker.
Step S13: according to the identifying information of selection instruction determination therapeutic progresses;
The identifying information of therapeutic progresses can show the identifying information of all therapeutic progresses corresponding with this therapeutic scheme after the identifying information selecting therapeutic scheme, selects for healthcare givers.
Step S14: after often determining the identifying information of a therapeutic progresses, receive input with a jth text message that identification marking information is corresponding;
After the identifying information determining a therapeutic progresses, all identification marking information corresponding with the identifying information of this therapeutic progresses can be shown, so that the medical record information that medical worker's input is corresponding with this identification marking information.
After determining the identifying information of therapeutic progresses, when medical worker clicks the jth corresponding with the identifying information of this therapeutic progresses identification marking information, Text Input window can be shown so that medical worker's input and this jth text message that identification marking information is corresponding (i.e. medical record information).
Wherein, j be more than or equal to 1 positive integer.
Step S15: when there being electronic health record to generate instruction generation, be added in described electronic health record foundation forms with the position of described jth identification marking information corresponding region in by what receive with a jth text message that identification marking information is corresponding according to the order of the identifying information of the therapeutic progresses preset, generate electronic health record.
Electronic health record generates instruction can trigger generation by medical worker.
In the embodiment of the present application, in advance the identifying information of therapeutic progresses is sorted.When having monitored electronic health record and having generated instruction generation, by corresponding from different therapeutic progresses information, but the different text message corresponding to same identification marking information is added in the text Adding Area corresponding to same identification marking information in electronic health record foundation forms by the clooating sequence of the identifying information of therapeutic progresses, generate electronic health record.
A kind of electronic health record generation method that the application provides, medical record information is divided into some parts, in the process generating electronic health record, according to patient identity identifying information and therapeutic scheme identifying information determination electronic health record foundation forms, electronic health record foundation forms comprises the identification marking information of each several part medical record information, wherein, the identifying information of identifying information at least one therapeutic progresses corresponding of described therapeutic scheme, several identification marking information in the corresponding described electronic health record foundation forms of identifying information of each therapeutic progresses, visible, in the embodiment of the present application, each identification marking information on electronic health record foundation forms is to the identifying information that should have at least one therapeutic progresses, therefore, in the embodiment of the present application, every part medical record information by under different therapeutic progresses to should part text message combine, that is, the electronic health record generation method that the embodiment of the present application provides, each several part medical record information is generated by the implementation step piecewise combination of therapeutic scheme, thus the complete electronic health record generated for the whole therapeutic process of patient, when medical record information viewed or edited by needs, medical worker only needs to view or edit an electronic health record, and no longer need to open multiple electronic health record, thus simplify the operation that medical worker views or edits electronic health record.
Usually, patient is after going to a doctor for the first time, medical personnel also may can require that patient goes to a doctor again according to the state of an illness of patient, and when patient goes to a doctor first and again go to a doctor, the medical record information that medical personnel records is different, such as, for first medical, the medical record information of medical personnel's record generally includes: patient basis, main suit, present illness history, past medical history, family history, whole body, inspection, treatment plan and disposal nine partial content; And for again going to a doctor, the medical record information of medical personnel's record generally includes: patient basis and further consultation, inspection and disposal four partial content.
For this, in the embodiment of the present application, first visit electronic health record foundation forms and further consultation electronic health record foundation forms can be integrated into an electronic health record foundation forms, wherein, this electronic health record foundation forms comprises patient basis's part, first visit electronic health record template part and further consultation electronic health record template part; First visit electronic health record template part and further consultation electronic health record template part respectively comprise some identification marking information.Such as, first visit electronic health record template part can comprise: the identification marking information such as main suit, present illness history, past medical history, family history, whole body, inspection, treatment plan and disposal; Further consultation electronic health record template part can comprise: the identification marking information such as further consultation, inspection and disposal.
In above-described embodiment, preferably, described template attributes information can also comprise:
Diagnostic-type information.Wherein, diagnostic-type can comprise first visit or further consultation.
Different electronic health record foundation forms can being prestored for different diagnostic-type information in the embodiment of the present application, when loading electronic health record foundation forms, the electronic health record foundation forms corresponding to this diagnostic-type can be loaded according to diagnostic-type information.
In above-described embodiment, preferably, by receive with a jth text message that identification marking information is corresponding according to preset therapeutic progresses order be added in text Adding Area corresponding with a described jth identification marking information in described electronic health record foundation forms time, a jth identification marking information can be searched to determine the text Adding Area corresponding with a described jth identification marking information in electronic health record foundation forms in the mode traveling through electronic health record foundation forms.
In above-described embodiment, preferably, describedly be added into a kind of realization flow figure in described electronic health record foundation forms with the position of described jth identification marking information corresponding region in as shown in Figure 2 with a jth text message that identification marking information is corresponding according to the therapeutic progresses order preset by what receive, can comprise:
Step S21: the positional information according to a described jth identification marking information searches a described jth identification marking information in described electronic health record foundation forms;
In the embodiment of the present application, prestore the positional information of each identification marking information in electronic health record foundation forms.
Step S22: determine the text Adding Area corresponding with a described jth identification marking information;
Step S23: successively corresponding with each therapeutic progresses is added in determined text Adding Area with a jth text message that identification marking information is corresponding according to the therapeutic progresses order preset.
In the embodiment of the present application, search a jth identification marking information according to the positional information of a jth identification marking information, make the location of a jth identification marking information more quick, thus electronic health record can be generated more fast.
Above-described embodiment, preferably, after generation electronic health record, can also comprise:
When receiving output order, export described electronic health record.
In the embodiment of the present application, export described electronic health record and comprise the described electronic health record of display, or, print described electronic health record.
Corresponding with embodiment of the method, the embodiment of the present application also provides a kind of electronic health record generation system, is applied to electronic equipment, and a kind of structural representation of the electronic health record generation system that the embodiment of the present application provides as shown in Figure 3, can comprise:
First determination module 31, load-on module 32, the second determination module 33, receiver module 34 and generation module 35; Wherein,
First determination module 31 is for foundation selection instruction determination template attributes information, and described template attributes information comprises: the identifying information of patient identity identifying information and therapeutic scheme;
In the embodiment of the present application, selection instruction by medical worker's clicking trigger, namely can click template attributes information by medical worker.
Wherein, the identifying information of patient identity can refer to the name of patient and/or the numbering of patient;
For different medical subject, can pre-determine this medical section diagnostic result that medical worker often assigns now according to actual conditions has which, and for certain diagnostic result, which the therapeutic scheme that medical worker often selects has again.
In the embodiment of the present application, can monitor for certain diagnostic result information click instruction after, namely after medical worker clicks diagnostic result, display the alternative therapeutic scheme corresponding with this diagnostic result information click for medical worker.
Load-on module 32 is for loading the electronic health record foundation forms corresponding with described template attributes information, and described electronic health record foundation forms comprises the identification marking information of each several part medical record information; Wherein, the identifying information of identifying information at least one therapeutic progresses corresponding of each therapeutic scheme, identifying information several identification marking information corresponding of each therapeutic progresses;
Electronic health record foundation forms can be prestored, after determining template attributes information, load this electronic health record foundation forms.
In the embodiment of the present application, can based on the therapeutic scheme implementation process of reality, set up the corresponding relation of therapeutic scheme identifying information and therapeutic progresses identifying information in advance, and the corresponding relation of some identification marking information in therapeutic progresses identifying information and electronic health record foundation forms.
After template attributes information has been selected, automatically can load electronic health record foundation forms, also can be triggered loading electronic health record foundation forms by medical worker.
Second determination module 33 is for the identifying information according to selection instruction determination therapeutic progresses;
The identifying information of therapeutic progresses can show the identifying information of all therapeutic progresses corresponding with this therapeutic scheme after the identifying information selecting therapeutic scheme, selects for healthcare givers.
Receiver module 34 for after described second determination module 33 determines the identifying information of an instruction step, receive input with a jth text message that identification marking information is corresponding; 31
After the identifying information determining a therapeutic progresses, all identification marking information corresponding with the identifying information of this therapeutic progresses can be shown, so that the medical record information that medical worker's input is corresponding with this identification marking information.
After the identifying information of the therapeutic progresses determined, when medical worker clicks the jth corresponding with the identifying information of this therapeutic progresses identification marking information, Text Input interface can be shown so that medical worker's input and this jth text message that identification marking information is corresponding (i.e. medical record information).
Wherein, j be more than or equal to 1 positive integer.
Generation module 35 is for when there being electronic health record to generate instruction generation, be added in described electronic health record foundation forms with described jth identification marking information corresponding text Adding Area in by what receive with a jth text message that identification marking information is corresponding according to the order of the identifying information of the therapeutic progresses preset, generate electronic health record.
Electronic health record generates instruction can trigger generation by medical worker.
In the embodiment of the present application, in advance the identifying information of therapeutic progresses is sorted.When having monitored electronic health record and having generated instruction generation, by corresponding from different therapeutic progresses information, but the different text message corresponding to same identification marking information is added in the text Adding Area corresponding to same identification marking information in electronic health record foundation forms by the clooating sequence of the identifying information of therapeutic progresses, generate electronic health record.
A kind of electronic health record generation system that the application provides, medical record information is divided into some parts, in the process generating electronic health record, according to patient identity identifying information and therapeutic scheme identifying information determination electronic health record foundation forms, electronic health record foundation forms comprises the identification marking information of each several part medical record information, wherein, the identifying information of identifying information at least one therapeutic progresses corresponding of described therapeutic scheme, several identification marking information in the corresponding described electronic health record foundation forms of identifying information of each therapeutic progresses, visible, in the embodiment of the present application, each identification marking information on electronic health record foundation forms is to the identifying information that should have at least one therapeutic progresses, therefore, in the embodiment of the present application, every part medical record information by under different therapeutic progresses to should part text message combine, that is, the electronic health record generation system that the embodiment of the present application provides, each several part medical record information is generated by the implementation step piecewise combination of therapeutic scheme, thus the complete electronic health record generated for the whole therapeutic process of patient, when medical record information viewed or edited by needs, medical worker only needs to view or edit an electronic health record, and no longer need to open multiple electronic health record, thus simplify the operation that medical worker views or edits electronic health record.
In above-described embodiment, preferably, described template attributes information can also comprise:
Diagnostic-type information.Wherein, diagnostic-type can comprise first visit or further consultation.
Different electronic health record foundation forms can be prestored for different diagnostic-type information in the embodiment of the present application, load-on module 32, when loading electronic health record foundation forms, can load the electronic health record foundation forms corresponding to this diagnostic-type according to diagnostic-type information.
In above-described embodiment, preferably, a kind of structural representation of generation module 35 as shown in Figure 4, can comprise:
First determining unit 41, second determining unit 42 and adding device 43; Wherein,
First determining unit 41 searches a described jth identification marking information for the positional information according to a described jth identification marking information in described electronic health record foundation forms;
In the embodiment of the present application, prestore the positional information of each identification marking information in electronic health record foundation forms.
Second determining unit 42 is for determining the text Adding Area corresponding with a described jth identification marking information;
Corresponding with the identifying information of various countries' therapeutic progresses is added in determined text Adding Area with a jth text message that identification marking information is corresponding for the order of the identifying information according to the therapeutic progresses preset by adding device 43 successively.
The another kind of structural representation of the electronic health record generation system that the embodiment of the present application provides as shown in Figure 5, can also comprise:
Output control module 51, for when receiving output order, exports described electronic health record.
In the embodiment of the present application, export described electronic health record and comprise the described electronic health record of display, or, print described electronic health record.
Those of ordinary skill in the art can recognize, in conjunction with unit and the algorithm steps of each example of embodiment disclosed herein description, can realize with the combination of electronic hardware or computer software and electronic hardware.These functions perform with hardware or software mode actually, depend on application-specific and the design constraint of technical scheme.Professional and technical personnel can use distinct methods to realize described function to each specifically should being used for, but this realization should not thought and exceeds scope of the present invention.
Those skilled in the art can be well understood to, and for convenience and simplicity of description, the system of foregoing description and the specific works process of unit, with reference to the corresponding process in preceding method embodiment, can not repeat them here.
In several embodiments that the application provides, should be understood that disclosed system and method can realize by another way.Such as, system embodiment described above is only schematic, such as, the division of described unit, be only a kind of logic function to divide, actual can have other dividing mode when realizing, such as multiple unit or assembly can in conjunction with or another system can be integrated into, or some features can be ignored, or do not perform.Another point, shown or discussed coupling each other or direct-coupling or communication connection can be by some interfaces, and the indirect coupling of system or unit or communication connection can be electrical, machinery or other form.
The described unit illustrated as separating component or can may not be and physically separates, and the parts as unit display can be or may not be physical location, namely can be positioned at a place, or also can be distributed in multiple network element.Some or all of unit wherein can be selected according to the actual needs to realize the object of the present embodiment scheme.
In addition, each functional unit in each embodiment of the present invention can be integrated in a processing unit, also can be that the independent physics of unit exists, also can two or more unit in a unit integrated.
If described function using the form of SFU software functional unit realize and as independently production marketing or use time, can be stored in a computer read/write memory medium.Based on such understanding, the part of the part that technical scheme of the present invention contributes to prior art in essence in other words or this technical scheme can embody with the form of software product, this computer software product is stored in a storage medium, comprising some instructions in order to make a computer equipment (can be personal computer, server, or the network equipment etc.) perform all or part of step of method described in each embodiment of the present invention.And aforesaid storage medium comprises: USB flash disk, portable hard drive, ROM (read-only memory) (ROM, Read-Only Memory), random access memory (RAM, Random Access Memory), magnetic disc or CD etc. various can be program code stored medium.
To the above-mentioned explanation of the disclosed embodiments, professional and technical personnel in the field are realized or uses the present invention.To be apparent for those skilled in the art to the multiple amendment of these embodiments, General Principle as defined herein can without departing from the spirit or scope of the present invention, realize in other embodiments.Therefore, the present invention can not be restricted to these embodiments shown in this article, but will meet the widest scope consistent with principle disclosed herein and features of novelty.
Claims (8)
1. an electronic health record generation method, is applied to electronic equipment, it is characterized in that, medical record information is divided into some parts, and described method comprises:
According to selection instruction determination template attributes information, described template attributes information comprises: the identifying information of patient identity identifying information and therapeutic scheme;
Load the electronic health record foundation forms corresponding with described template attributes information, described electronic health record foundation forms comprises the identification marking information of each several part medical record information; Wherein, the identifying information of identifying information at least one therapeutic progresses corresponding of described therapeutic scheme, several identification marking information in the corresponding described electronic health record foundation forms of identifying information of each therapeutic progresses;
According to the identifying information of selection instruction determination therapeutic progresses;
After often determining the identifying information of a therapeutic progresses, receive input with a jth text message that identification marking information is corresponding;
When there being electronic health record to generate instruction generation, be added in described electronic health record foundation forms with described jth identification marking information corresponding text Adding Area in by what receive with a jth text message that identification marking information is corresponding according to the order of the identifying information of the therapeutic progresses preset, generate electronic health record.
2. method according to claim 1, is characterized in that, described template attributes information also comprises: diagnostic-type information.
3. method according to claim 1, it is characterized in that, described being added in text Adding Area corresponding with a described jth identification marking information in described electronic health record foundation forms according to the order of identifying information of the therapeutic progresses preset with a jth text message that identification marking information is corresponding of receiving to be comprised:
Positional information according to a described jth identification marking information searches a described jth identification marking information in described electronic health record foundation forms;
Determine the text Adding Area corresponding with a described jth identification marking information;
Successively corresponding with each therapeutic progresses is added in determined text Adding Area with a jth text message that identification marking information is corresponding according to the order of the identifying information of the therapeutic progresses preset.
4. the method according to claim 1-3 any one, is characterized in that, after generation electronic health record, also comprises:
When receiving output order, export described electronic health record.
5. an electronic health record generation system, in electronic equipment, should is characterized in that, medical record information is divided into some parts, and described system comprises:
First determination module, for foundation selection instruction determination template attributes information, described template attributes information comprises: the identifying information of patient identity identifying information and therapeutic scheme;
Load-on module, for loading the electronic health record foundation forms corresponding with described template attributes information, described electronic health record foundation forms comprises the identification marking information of each several part medical record information; Wherein, the identifying information of identifying information at least one therapeutic progresses corresponding of each therapeutic scheme, identifying information several identification marking information corresponding of each therapeutic progresses;
Second determination module, for the identifying information according to selection instruction determination therapeutic progresses;
Receiver module, for after described second determination module determines the identifying information of an instruction step, receive input with a jth text message that identification marking information is corresponding;
Generation module, for when there being electronic health record to generate instruction generation, be added in described electronic health record foundation forms with described jth identification marking information corresponding text Adding Area in by what receive with a jth text message that identification marking information is corresponding according to the order of the identifying information of the therapeutic progresses preset, generate electronic health record.
6. system according to claim 5, is characterized in that, described template attributes information also comprises: diagnostic-type information.
7. system according to claim 5, is characterized in that, described generation module comprises:
First determining unit, searches a described jth identification marking information for the positional information according to a described jth identification marking information in described electronic health record foundation forms;
Second determining unit, for determining the text Adding Area corresponding with a described jth identification marking information;
Adding device, for being added into corresponding with the identifying information of each therapeutic progresses in determined text Adding Area with a jth text message that identification marking information is corresponding successively according to the order of the therapeutic progresses identification marking information preset.
8. the system according to claim 5-7 any one, is characterized in that, also comprises:
Output control module, for when receiving output order, exports described electronic health record.
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| CN104835098A (en) * | 2015-05-15 | 2015-08-12 | 上海翼依信息技术有限公司 | Medical record electronic data identification method and system thereof |
| CN107103197A (en) * | 2017-04-26 | 2017-08-29 | 浙江宁格医疗科技有限公司 | A kind of smart electronicses medical record management method and its system |
| CN107229831A (en) * | 2017-06-08 | 2017-10-03 | 成都深泉科技有限公司 | Electronic health record generation method, apparatus and system |
| CN107463776A (en) * | 2017-07-26 | 2017-12-12 | 深圳市坐标软件开发有限公司 | WEB terminal electronic health record generation method and system are realized based on B/S frameworks |
| CN108197096A (en) * | 2018-02-01 | 2018-06-22 | 东莞久久蜜蜂智能科技有限公司 | Information input method, Message Entry Device and system |
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| CN104835098A (en) * | 2015-05-15 | 2015-08-12 | 上海翼依信息技术有限公司 | Medical record electronic data identification method and system thereof |
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| CN107229831A (en) * | 2017-06-08 | 2017-10-03 | 成都深泉科技有限公司 | Electronic health record generation method, apparatus and system |
| CN107463776A (en) * | 2017-07-26 | 2017-12-12 | 深圳市坐标软件开发有限公司 | WEB terminal electronic health record generation method and system are realized based on B/S frameworks |
| CN108197096A (en) * | 2018-02-01 | 2018-06-22 | 东莞久久蜜蜂智能科技有限公司 | Information input method, Message Entry Device and system |
| CN108415891A (en) * | 2018-02-10 | 2018-08-17 | 武汉大学中南医院 | A kind of Emergency call structured electronic case generation method and system |
| CN109524072A (en) * | 2018-05-28 | 2019-03-26 | 平安医疗健康管理股份有限公司 | Electronic health record generation method, device, computer equipment and storage medium |
| CN109524072B (en) * | 2018-05-28 | 2024-06-28 | 深圳平安医疗健康科技服务有限公司 | Electronic medical record generation method, device, computer equipment and storage medium |
| CN111292817A (en) * | 2018-12-07 | 2020-06-16 | 深圳坐标软件集团有限公司 | Electronic medical record generation method and device |
| CN110196670A (en) * | 2019-05-31 | 2019-09-03 | 数坤（北京）网络科技有限公司 | A kind of document creation method, equipment and computer readable storage medium |
| CN111613282A (en) * | 2020-04-30 | 2020-09-01 | 卫宁健康科技集团股份有限公司 | Cloud medical record construction method, system, equipment and medium for disaster site |
| CN112397170A (en) * | 2020-12-01 | 2021-02-23 | 山东勤成健康科技股份有限公司 | Electronic medical record generation method and device |
| CN113486644A (en) * | 2021-07-27 | 2021-10-08 | 北京康惠达科技有限公司 | Method, system, terminal and storage medium for quickly generating medical document |
| CN113793677A (en) * | 2021-08-24 | 2021-12-14 | 挂号网（杭州）科技有限公司 | Electronic medical record management method and device, storage medium and electronic equipment |
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