CN105808951A - Quality control method and apparatus for electronic medical record - Google Patents
Quality control method and apparatus for electronic medical record Download PDFInfo
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- CN105808951A CN105808951A CN201610135886.XA CN201610135886A CN105808951A CN 105808951 A CN105808951 A CN 105808951A CN 201610135886 A CN201610135886 A CN 201610135886A CN 105808951 A CN105808951 A CN 105808951A
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- G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H10/00—ICT specially adapted for the handling or processing of patient-related medical or healthcare data
- G16H10/60—ICT specially adapted for the handling or processing of patient-related medical or healthcare data for patient-specific data, e.g. for electronic patient records
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Abstract
The invention is suitable for the technical field of medical system informationization and provides a quality control method for an electronic medical record. The method comprises the steps of obtaining electronic medical record data, wherein the electronic medical record data is structured electronic medical record data; judging whether the electronic medical record data meets a quality control condition or not; according to a judgment result and a quality control rule corresponding to the quality control condition, obtaining a quality score of the electronic medical record; and storing the quality score of the electronic medical record. According to an embodiment of the invention, the step of scoring the structured electronic medical record data is added, so that a doctor can visually know a true condition of the medical record through the quality score, the quality control doctor can finish the quality control of the medical record through the configured quality control condition, and a handling process of the quality control doctor is greatly simplified; and meanwhile, in the whole quality control process, the doctor can configure the required quality control condition, so that the quality score can more truly reflect the quality condition of the electronic medical record.
Description
Technical field
The invention belongs to the informationalized technical field of medical system, particularly relate to method of quality control and the device thereof of a kind of electronic health record.
Background technology
Case history refers to the summation of the data such as word that medical worker formed in curative activity process, chart, image, section, is the data with legal sense, is the strong testimonial material of converse onus probation.In today that information technology is growing, electronic medical record system is popularized gradually at situation of all-level hospitals, compare over traditional papery case history, electronic health record has to be write convenience convenient, mutual, accesses the features such as flexible, its appearance facilitates medical worker and writes and inquire about, improve work efficiency, but also show some medical record quality problems, and become the important component part of medical quality managent.Along with the deep application of electronic health record, controlling to provide new platform for quality of case history, the real-time Quality Control of electronic health record becomes and is likely to how to have managed electronic health record quality and has become as a new problem of hospital quality management department.
At present, there is very big limitation in electronic health record quality control system function.Although existing scheme discloses how realizes automatically checking and error correction of structured patient record, but this scheme cannot be applicable to whole quality control process, the case history that the Quality Control doctor being responsible for quality of case history control specially need nonetheless remain for manually clinician being filled in is estimated checking, cause that quality control process efficiency is low, processing procedure is delayed, it is impossible to reflection quality of case history situation in time.
Summary of the invention
The embodiment of the present invention provides method of quality control and the device thereof of a kind of electronic health record, it is intended to solving electronic health record quality control process needs the technical problem that manual review, matter sky flow path efficiency are low, cannot react quality of case history situation in time.
The embodiment of the present invention is achieved in that the method for quality control of a kind of electronic health record, comprises the following specific steps that:
Obtaining electronic health record data, described electronic health record data are the data of structured electronic patient record；
Judge whether described electronic health record data meet Quality Control condition；
According to the Quality control rules that judged result is corresponding with described Quality Control condition, obtain the quality score of described electronic health record；
Store the described quality score of described electronic health record.
The embodiment of the present invention also provides for the quality control apparatus of a kind of electronic health record, it is characterised in that including:
Data capture unit, is used for obtaining electronic health record data, and described electronic health record data are the data of structured electronic patient record；
Condition judgment unit, is used for judging whether described electronic health record data meet Quality Control condition；
Scores of medical records unit, for the Quality control rules corresponding with described Quality Control condition according to judged result, obtains the quality score of described electronic health record；And
Memory element, stores the described quality score of described electronic health record.
The method of quality control of a kind of electronic health record disclosed by the invention, set up the step that structured electronic patient record data are marked, not only enable the surgeon to be understood intuitively the truth of case history by quality score, so that Quality Control doctor can pass through the Quality Control condition configured, complete the quality control of case history voluntarily, thus enormously simplify the processing procedure of Quality Control doctor, and then improve quality control process efficiency, simultaneously, in whole quality control process, doctor can quality control conditions required for autonomous configuration, make quality score can reflect the quality condition of electronic health record more truly.
Accompanying drawing explanation
Fig. 1 is a kind of working environment figure of the method for quality control of a kind of electronic health record that the embodiment of the present invention provides；
Fig. 2 is the flow chart of the method for quality control of a kind of electronic health record that the embodiment of the present invention provides；
Fig. 3 is the described flow chart judging whether described electronic health record data meet Quality Control condition that the embodiment of the present invention provides；
Fig. 4 is the Quality control rules corresponding with described Quality Control condition according to judged result that the embodiment of the present invention provides, and obtains the flow chart of the quality score of described electronic health record；
Fig. 5 is the flow chart of the method for quality control of a kind of electronic health record that the embodiment of the present invention provides；
Fig. 6 is the method for quality control of a kind of electronic health record that the embodiment of the present invention the provides flow chart when practice；
Fig. 7 is the structure chart of the quality control apparatus of a kind of electronic health record that the embodiment of the present invention provides；
Fig. 8 is the structure chart of the described condition judgment unit that the embodiment of the present invention provides；
Fig. 9 is the structure chart of the described scores of medical records unit that the embodiment of the present invention provides；
Figure 10 is another structure chart of the quality control apparatus of a kind of electronic health record that the embodiment of the present invention provides；
Figure 11 be the embodiment of the present invention provide a kind of electronic health record quality control apparatus in the client be embodied as surface chart.
Detailed description of the invention
In order to make the purpose of the present invention, technical scheme and advantage clearly understand, below in conjunction with drawings and Examples, the present invention is further elaborated.Should be appreciated that specific embodiment described herein is only in order to explain the present invention, is not intended to limit the present invention.
The embodiment of the present invention is according to user configured Quality control rules, adopt the mode of automatic scoring, obtain the quality score of electronic health record data, and store it in electronic health record data, make Quality Control doctor without hand inspection circuit medical record data, but obtain the quality score of Current electronic case history automatically, intuitively, to understand the quality condition of Current electronic case history, enormously simplify the Quality Control flow process of Quality Control doctor.
Fig. 1 illustrates a kind of working environment of the method for quality control of a kind of electronic health record that the embodiment of the present invention provides.
The embodiment of the present invention is by obtaining electronic health record data in data base, according to the Quality Control condition configured and Quality control rules, obtain can the quality score of actual response quality of case history situation, and in time this quality score is stored to data base.
In embodiments of the present invention, being provided with the data base for storing electronic health record data in described server, client obtains the content in data base by the link with server.
Wherein, user, i.e. doctor, carry out checking and amendment of electronic health record by the client being connected with described server.User now had both included being clinician, also included the Quality Control doctor of Quality Control Department.
Described client can be the mobile terminal such as mobile phone, flat board, it is also possible to be the process equipment such as computer.
Now, between client and server, carry out data exchange by LAN, between server and data base, then carry out data exchange by wide area network, and multiple server can also be connected with each other.
Embodiment 1:
Fig. 2 illustrates the flow process of the method for quality control of a kind of electronic health record that embodiments of the invention provide, and details are as follows:
In step s 201, electronic health record data are obtained.
Wherein, described electronic health record data are the data of structured electronic patient record.Described electronic health record data are have the set of the patient information in the structured electronic patient record of four layers of storage organization, and four layers of described storage organization include metadata, data set, document section and case history document, and its concrete practice situation is as follows:
1) metadata: include symptom metadata, anatomical site metadata, tempon data, quantity metadata, logical judgment metadata etc., as " diarrhoea " belongs to symptom metadata.
2) data set: be made up of several metadata, the paragraph as described " diarrhoea " this symptom belongs to data set, and wherein, data set can include picture.
3) document section: be made up of several data sets and/or metadata, the history of present illness describing paragraph as included " diarrhoea " symptom belongs to document section.
4) case history document: be made up of several document sections and/or metadata, the outpatient service record as included history of present illness and personal patient information belongs to case history document.
In embodiments of the present invention, electronic health record includes several case history documents, and user can select appropriate medical record templates in the client, and by choosing different medical terminologys, completes filling in of electronic health record.It is to say, the embodiment of the present invention completes to meet the structuring Input Process of the patient information of medical document form in the way of natural language.
In step S202, it is judged that whether described electronic health record data meet Quality Control condition.
In an embodiment of the present invention, described Quality Control condition is for judging whether described electronic health record meets predetermined quality level, and described Quality Control condition had both included the Quality Control condition that system is built-in, also included user-defined Quality Control condition.
Wherein, described Quality Control condition at least include whether to set up case history in the given time, whether exist crucial paragraph disappearance, medical record data whether exist mistake, diagnosis data whether meet symptom describe and medical vocabulary whether use correct one of them.
Owing to Different hospital, different department are inevitable different for the requirement of case history, therefore, in order to expand the use scope of method of quality control, the embodiment of the present invention adopts configurable Quality Control condition, propose a kind of method that Different hospital, different department all can use same quality management, effectively prevent electronic health record quality management when across hospital, Trans-Provincial/Municipal and be likely to the difficulty faced.
In step S203, according to the Quality control rules that judged result is corresponding with described Quality Control condition, obtain the quality score of described electronic health record.
Now, Quality control rules can be carried out configured in advance by special Quality Control doctor, to realize unified management；Can also by clinician's sets itself, in order to case history oneself can be marked by doctor under different clinical settings.
In embodiments of the present invention, different Quality Control conditions can be corresponding with a Quality control rules, it is also possible to respectively at different Quality control rules one_to_one corresponding.
In step S204, store the quality score of described electronic health record.
The embodiment of the present invention is for the low technical problem of prior art electronic health record Quality Control flow path efficiency, set up the step that structured electronic patient record data are marked, not only enable the surgeon to be understood intuitively the truth of case history by quality score, so that Quality Control doctor can pass through the Quality Control condition configured, complete the quality control of case history voluntarily, thus enormously simplify the processing procedure of Quality Control doctor, and then improve quality control process efficiency, simultaneously, in whole quality control process, doctor can quality control conditions required for autonomous configuration, make quality score can reflect the quality condition of electronic health record more truly.
In embodiments of the present invention, quality score is applicable not only to oneself's scoring of clinician, but also be applicable to Quality Control doctor and filling in of clinician is circulated scoring, even can also suitable in the selective examination scoring link whole quality of case history control flow, thus forming a kind of active three grades of Quality Control patterns of case history, the Quality Control flow path efficiency making electronic health record is fast, validity is high, solves the technical problem that cannot react quality of case history situation in existing case history quality control method in time, truly.
Certainly, the method of quality control of the embodiment of the present invention is not restricted to the utilization of electronic health record, as long as the quality control of document complicated for data, that contain much information, the such as legal documents of personal credit record or contract class, can use the method for quality control of the embodiment of the present invention to improve efficiency.
Embodiment 2:
In embodiments of the present invention, described Quality Control condition is for whether diagnosis data meet symptom description.
Fig. 3 illustrates the described flow process judging whether described electronic health record data meet Quality Control condition that the embodiment of the present invention provides, and details are as follows:
In step S301, obtain the diagnosis data in electronic health record data and symptom describes.
In step s 302, resolve described symptom and describe, obtain the key words about disease during several symptoms describe.
Such as, symptom describes the situation of the menoxenia essentially describing a female patients, and now, the key words about disease should include the words such as " menstruation ", " stomachache ", " persistent period ".
Owing to the structured storage of electronic health record is very general, therefore, the embodiment of the present invention is for the electronic health record data based on structured storage, and the process how going out key words in structurized electronic health record data parsing is the known processing links of those skilled in the art, does not repeat them here.
In step S303, described key words and critical values and described diagnosis data are compared, it is judged that whether diagnosis data include the synonym word of at least one key words or key words.
Owing to the description of the technical term of different syndromes all differs, therefore, in embodiments of the present invention, the definition of pain synonym word can be arranged in advance by Quality Control doctor, it is also possible to by clinician voluntarily by Quality Control condition setting.
Wherein, above-mentioned judge process is based on the real-time typing of clinician, say, that, clinician is when filling in electronic health record, system obtains symptom in real time and describes data, and after clinician terminates to fill in, the symptom reminding doctor current describes whether meet diagnosis data.
Embodiment 3:
In embodiments of the present invention, the quantity of described Quality Control condition is two or more than two.
Should apply to a plurality of Quality Control condition and be simultaneously used for the situation of electronic health record scoring process.
Fig. 4 illustrates the Quality control rules corresponding with described Quality Control condition according to judged result that the embodiment of the present invention provides, and obtains the flow process of the quality score of described electronic health record.The quantity of described Quality Control condition is two or more than two.Details are as follows:
In step S401, according to described judged result, obtain the grade scoring that described Quality Control condition is corresponding.
Such as, when Quality Control condition is for " whether RAN completed within 24 hours ", if it is judged that be "Yes", then grade scoring is " 10 points ", represents and adds 10 points；If it is judged that be "No", then grade scoring is "-10 points ", represents 10 points of button.
In step S402, according to the weights that described grade scoring is corresponding with described Quality Control condition, obtain the quality score of described electronic health record data
Now, when the quantity of Quality Control condition is unique, the grade scoring obtained in step S401, it is the quality score of Current electronic medical record data.
Such as, the weight setting of a Quality Control condition is 9, and the weight setting of another Quality Control condition is 5, then now the quality score of electronic health record data is the summation after grade scoring corresponding to Quality Control condition is multiplied with its weights.
Wherein, for the computing mode of the weighted sum in the embodiment of the present invention, user according to the standards of grading of different department, Different hospital self, can adjust weights at any time, it is of course also possible to by the special same configuration of Quality Control doctor, in order to unified management.
In step S403, when described quality score is not up to threshold value, generate corresponding information.
Now, the generation of described information both can before the step of the quality score of the described electronic health record of described storage, namely before step S204；Can also after step S204.The former can apply to electronic health record oneself's scoring at clinical stage so that before storage quality score, clinician can repeatedly revise electronic health record, to reduce the work difficulty of subsequent quality scoring step；And the latter can apply to the electronic health record circulation Quality Control in whole hospital so that Quality Control doctor obtains the quality condition of electronic health record as early as possible, to ensure in the Quality Control Links that Quality Control department of hospital can get involved electronic health record quickly, in time.Certainly, user according to actual needs, can select appropriate prompt time.
Embodiment 4:
Fig. 5 illustrates the flow process of the method for quality control of a kind of electronic health record that the embodiment of the present invention provides, and details are as follows:
After step s 204, step S501 is also included.
In step S501, according to described quality score, electronic health record is ranked up from small to large according to quality score.
In embodiments of the present invention, special Quality Control doctor can pass through ranking system, directly obtains the electronic health record that scoring is minimum, quality is worst, in order to carries out quality of case history targetedly and controls, thus reducing follow-up retrieval or classification time, facilitate the operation of Quality Control doctor.
Embodiment 5:
Fig. 6 illustrates the method for quality control of a kind of electronic health record that the embodiment of the present invention the provides flow process when practice, and details are as follows:
In step s 601, personal information and the clinical disease information of medical patient are recorded by clinician, form structurized electronic health record, and the patient information in described electronic health record is uploaded to data base.
In step S602, clinician configures Quality Control condition and Quality control rules voluntarily.
Now, clinician both can obtain Quality Control condition and the Quality control rules of needs from another data base, it is also possible to interim newly-built Quality Control condition and Quality control rules, and is uploaded to another data base after completing editor.
Wherein, described Quality Control condition at least include whether to set up case history in the given time, whether exist crucial paragraph disappearance, medical record data whether exist mistake, diagnosis data whether meet symptom describe and medical vocabulary whether use correct one of them.
In step S603, according to described Quality Control condition, obtain the grade scoring that described Quality Control condition is corresponding.
In step s 604, it is judged that whether the quantity of Quality Control condition carrying out judging with described electronic health record data is more than one, if it is, go to step S605；If it is not, then go to step S606.
In step s 605, according to described grade scoring, the quality score of described electronic health record data is obtained.
In step S606, according to the weights that described grade scoring is corresponding with described Quality Control condition, obtain the quality score of described electronic health record data.
In step S607, Quality Control doctor is according to predetermined scoring threshold value, it is judged that whether the quality score of the electronic health record that clinician fills in reaches predeterminated level, if it is, go to step S608；If it is not, then go to step S609.
In step S608, generate the identification information that quality of case history is qualified, and be uploaded to data base, go to step S610.
In step S609, generate the information that quality of case history scoring requires not up to predetermined scoring, and transmit it to clinician, remind clinician's amendment, return to step S601.
In step S610, according to described quality score, the electronic health record in data base is ranked up from small to large according to quality score, completes case history Quality Control flow process.
One of ordinary skill in the art will appreciate that, realize all or part of step in said method embodiment and can be by program and what relevant hardware completed, described program can be stored in the storage medium of an embodied on computer readable, described storage medium, such as ROM/RAM, disk, CD, flash memory disk etc..
Embodiment 6:
Fig. 7 illustrates the structure of the quality control apparatus of a kind of electronic health record that the embodiment of the present invention provides, and for the ease of illustrating, only illustrates the part relevant to the embodiment of the present invention.
In embodiments of the present invention, the quality control apparatus of described electronic health record includes data capture unit 701, condition judgment unit 702, scores of medical records unit 703 and memory element 704, wherein:
Data capture unit 701, is used for obtaining electronic health record data.
Wherein, described electronic health record data store in a structured manner.Described electronic health record data are the set by having the stored patient information of the medical record templates of four layers of storage organization, and four layers of described storage organization include metadata, data set, document section and case history document, and its concrete practice situation is as follows:
1) metadata: include symptom metadata, anatomical site metadata, tempon data, quantity metadata, logical judgment metadata etc., as " diarrhoea " belongs to symptom metadata.
2) data set: be made up of several metadata, the paragraph as described " diarrhoea " this symptom belongs to data set, and wherein, data set can include picture.
3) document section: be made up of several data sets and/or metadata, the history of present illness describing paragraph as included " diarrhoea " symptom belongs to document section.
4) case history document: be made up of several document sections and/or metadata, the outpatient service record as included history of present illness and personal patient information belongs to case history document.
In embodiments of the present invention, medical record templates includes several case history documents, and user can select appropriate medical record templates in the client, and by choosing different medical terminologys, completes filling in of medical record templates.It is to say, the embodiment of the present invention completes to meet the structuring Input Process of the patient information of medical document form in the way of natural language.
Condition judgment unit 702, is used for judging whether described electronic health record data meet Quality Control condition.
In an embodiment of the present invention, described Quality Control condition is for judging whether described electronic health record meets predetermined quality level, and described Quality Control condition had both included the Quality Control condition that system is built-in, also included user-defined Quality Control condition.
Wherein, described Quality Control condition at least include whether to set up case history in the given time, whether exist crucial paragraph disappearance, medical record data whether exist mistake, diagnosis data whether meet symptom describe, medical vocabulary whether use correct one of them
Owing to Different hospital, different department are inevitable different for the requirement of case history, therefore, in order to expand the use scope of method of quality control, the embodiment of the present invention adopts configurable Quality Control condition, propose a kind of method that Different hospital, different department all can use same quality management, effectively prevent electronic health record quality management when across hospital, Trans-Provincial/Municipal and be likely to the difficulty faced.
Scores of medical records unit 703, for the Quality control rules corresponding with described Quality Control condition according to judged result, obtains the quality score of described electronic health record.
Now, Quality control rules can be carried out configured in advance by special Quality Control doctor, to realize unified management；Can also by clinician's sets itself, in order to case history oneself can be marked by doctor under different clinical settings.
In embodiments of the present invention, different Quality Control conditions can be corresponding with a Quality control rules, it is also possible to respectively at different Quality control rules one_to_one corresponding.
Memory element 704, for storing the quality score of described electronic health record.
The embodiment of the present invention is for the low technical problem of prior art electronic health record Quality Control flow path efficiency, set up the step that structured electronic patient record data are marked, not only enable the surgeon to be understood intuitively the truth of case history by quality score, so that Quality Control flow process has only to transmission quality score rather than the patient information contained much information, thus substantially reducing the transmission time of electronic health record, and then realize in time, reaction quality of case history situation truly, simultaneously, in whole quality control process, doctor can quality control conditions required for autonomous configuration, make quality score can reflect the quality condition of electronic health record more truly.
In embodiments of the present invention, quality score is applicable not only to oneself's scoring of clinician, but also be applicable to Quality Control doctor and filling in of clinician is circulated scoring, even can also suitable in the selective examination scoring link whole quality of case history control flow, thus forming a kind of active three grades of Quality Control patterns of case history, the Quality Control flow path efficiency making electronic health record is fast, validity is high, solves the technical problem that cannot react quality of case history situation in existing case history quality control method in time, truly.
Certainly, the method of quality control of the embodiment of the present invention is not restricted to the utilization of electronic health record, as long as the quality control of document complicated for data, that contain much information, the such as legal documents of personal credit record or contract class, can use the method for quality control of the embodiment of the present invention to improve efficiency.
Embodiment 7:
In embodiments of the present invention, described Quality Control condition is for whether diagnosis data meet symptom description.
Fig. 8 illustrates the structure of the described condition judgment unit 702 that the embodiment of the present invention provides, and for the ease of illustrating, only illustrates the part relevant to the embodiment of the present invention, wherein:
Data acquisition module 801, is used for the diagnosis data and the symptom description that obtain in electronic health record data.
Parsing module 802, resolves described symptom and describes, and obtains the key words about disease during several symptoms describe,
Such as, symptom describes the situation of the menoxenia essentially describing a female patients, and now, the key words about disease should include the words such as " menstruation ", " stomachache ", " persistent period ".
Owing to the structured storage of electronic health record is very general, therefore, the embodiment of the present invention is for the electronic health record data based on structured storage, and the process how going out key words in structurized electronic health record data parsing is the known processing links of those skilled in the art, does not repeat them here.
Conditional judgment module 803, for comparing described key words and critical values and described diagnosis data, it is judged that diagnose the synonym word whether including at least one key words or key words in data.
Owing to the description of the technical term of different syndromes all differs, therefore, in embodiments of the present invention, the definition of pain synonym word can be arranged in advance by Quality Control doctor, it is also possible to by clinician voluntarily by Quality Control condition setting.
Wherein, above-mentioned judge process is based on the real-time typing of clinician, say, that, clinician is when filling in electronic health record, system obtains symptom in real time and describes data, and after clinician terminates to fill in, the symptom reminding doctor current describes whether meet diagnosis data.
Embodiment 8:
In embodiments of the present invention, the quantity of Quality Control condition described in described Quality control rules is two or more than two.
Now, weights should apply to a plurality of Quality Control condition and are simultaneously used for the situation of electronic health record scoring process.
Fig. 9 illustrates that the embodiment of the present invention provides the structure of described scores of medical records unit 803, for the ease of illustrating, only illustrates the part relevant to the embodiment of the present invention, wherein:
Grading module 901, for according to described judged result, obtaining the grade scoring that described Quality Control condition is corresponding.
Such as, when Quality Control condition is for " whether RAN completed within 24 hours ", if it is judged that be "Yes", then grade scoring is " 10 points ", represents and adds 10 points；If it is judged that be "No", then grade scoring is "-10 points ", represents 10 points of button.
Computing module 902, for the weights corresponding with described Quality Control condition according to described grade scoring, obtains the quality score of described electronic health record data.
Now, when the quantity of Quality Control condition is unique, the grade scoring that institute's scoring module 901 obtains, it is the quality score of Current electronic medical record data.
Such as, the weight setting of a Quality Control condition is 9, and the weight setting of another Quality Control condition is 5, then now the quality score of electronic health record data is the summation after grade scoring corresponding to Quality Control condition is multiplied with its weights.
Wherein, for the computing mode of the weighted sum in the embodiment of the present invention, user according to the standards of grading of different department, Different hospital self, can adjust weights at any time, it is of course also possible to by the special same configuration of Quality Control doctor, in order to unified management.
Reminding module 901, for when described quality score is not up to threshold value, generating corresponding information.
Now, the generation of described information both can before the step of the quality score of the described electronic health record of described storage, namely before step S204；Can also after step S204.The former can apply to electronic health record oneself's scoring at clinical stage so that before storage quality score, clinician can repeatedly revise electronic health record, to reduce the work difficulty of subsequent quality scoring step；And the latter can apply to the electronic health record circulation Quality Control in whole hospital so that Quality Control doctor obtains the quality condition of electronic health record as early as possible, to ensure in the Quality Control Links that Quality Control department of hospital can get involved electronic health record quickly, in time.Certainly, user according to actual needs, can select appropriate prompt time.
Embodiment 9:
Figure 10 illustrates another structure of the quality control apparatus of a kind of electronic health record of the embodiment of the present invention, for the ease of illustrating, only illustrates the part relevant to the embodiment of the present invention, including:
Sequencing unit 1001, for according to described quality score, being ranked up electronic health record from small to large according to quality score.
In embodiments of the present invention, special Quality Control doctor can pass through ranking system, directly obtains the electronic health record that scoring is minimum, quality is worst, in order to carries out quality of case history targetedly and controls, thus reducing follow-up retrieval or classification time, facilitate the operation of Quality Control doctor.
Embodiment 10:
Figure 11 illustrate the quality control apparatus of a kind of electronic health record that the embodiment of the present invention provides in the client be embodied as interface, details are as follows:
When clinician completes after electronic health record fills in, select self-appraisal link, then the Quality control rules of electronic health record and Quality Control scoring will be shown in the left side of electronic health record.Quality control rules now includes: 1, the deadline of the RAN document in the electronic health record of this patient should complete within 24 hours；2, the record of the history of disease of patient not should be empty by clinician；3, electronic health record should include the essential information of this patient, if the item number that essential information is sky is more than 1, then belongs to underproof electronic health record；4, the credit rating of this electronic health record should reach within 8 hours qualified.
The foregoing is only presently preferred embodiments of the present invention, not in order to limit the present invention, all any amendment, equivalent replacement and improvement etc. made within the spirit and principles in the present invention, should be included within protection scope of the present invention.
Claims (10)
1. the method for quality control of an electronic health record, it is characterised in that comprise the following specific steps that:
Obtaining electronic health record data, described electronic health record data are the data of structured electronic patient record；
Judge whether described electronic health record data meet Quality Control condition；
According to the Quality control rules that judged result is corresponding with described Quality Control condition, obtain the quality score of described electronic health record；
Store the described quality score of described electronic health record.
2. the method for claim 1, it is characterized in that, described Quality Control condition at least includes whether to set up case history in the given time, whether there is crucial paragraph disappearance, whether medical record data exists mistake, diagnosis data whether meet symptom describe and medical vocabulary whether use correct one of them.
3. method as claimed in claim 2, it is characterised in that whether described Quality Control condition meets symptom for diagnosis data describes；
Described judge whether described electronic health record data meet Quality Control condition, specifically include following steps:
Obtain the diagnosis data in electronic health record data and symptom describes；
Resolve described symptom to describe, obtain the key words about disease during several symptoms describe；
Described key words and critical values and described diagnosis data are compared, it is judged that whether diagnosis data include the synonym word of at least one key words or key words.
4. the method for claim 1, it is characterised in that the quantity of described Quality Control condition is two or more than two；
The described Quality control rules corresponding with described Quality Control condition according to judged result, obtains the quality score of described electronic health record, specifically includes following steps:
According to described judged result, obtain the grade scoring that described Quality Control condition is corresponding；
According to the weights that described grade scoring is corresponding with described Quality Control condition, obtain the quality score of described electronic health record data；
When described quality score is not up to threshold value, generate corresponding information.
5. the method for claim 1, it is characterised in that after the quality score step of the described electronic health record of described storage, also includes:
According to described quality score, electronic health record is ranked up from small to large according to quality score.
6. the quality control apparatus of an electronic health record, it is characterised in that including:
Data capture unit, is used for obtaining electronic health record data, and described electronic health record data are the data of structured electronic patient record；
Condition judgment unit, is used for judging whether described electronic health record data meet Quality Control condition；
Scores of medical records unit, for the Quality control rules corresponding with described Quality Control condition according to judged result, obtains the quality score of described electronic health record；And
Memory element, stores the described quality score of described electronic health record.
7. device as claimed in claim 6, it is characterized in that, described Quality Control condition at least includes whether to set up case history in the given time, whether there is crucial paragraph disappearance, whether medical record data exists mistake, whether diagnosis data meet symptom describes and whether medical vocabulary uses correct one of them.
8. device as claimed in claim 7, it is characterised in that whether described Quality Control condition meets symptom for diagnosis data describes；
Described condition judgment unit includes:
Data acquisition module, is used for the diagnosis data and the symptom description that obtain in electronic health record data；
Parsing module, is used for resolving described symptom and describes, and obtains the key words about disease during several symptoms describe；And
Conditional judgment module, for comparing described key words and critical values and described diagnosis data, it is judged that diagnose the synonym word whether including at least one key words or key words in data.
9. device as claimed in claim 8, it is characterised in that the quantity of described Quality Control condition is two or more than two；
Described scores of medical records unit includes:
Grading module, for according to described judged result, obtaining the grade scoring that described Quality Control condition is corresponding；And
Computing module, for the weights corresponding with described Quality Control condition according to described grade scoring, obtains the quality score of described electronic health record data；
Reminding module, for when described quality score is not up to threshold value, generating corresponding information.
10. device as claimed in claim 6, it is characterised in that also include:
Sequencing unit, for according to described quality score, being ranked up electronic health record from small to large according to quality score.
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