CN105844566A

CN105844566A - Electronic medical record filing management system and electronic medical record filing management method

Info

Publication number: CN105844566A
Application number: CN201610177389.6A
Authority: CN
Inventors: 薛向东; 韩士斌; 苏明亮; 郭宗涛; 侯健; 杨丰华
Original assignee: Dong Hua Software Co Shares
Current assignee: Dong Hua Software Co Shares; DHC Software Co Ltd
Priority date: 2016-03-25
Filing date: 2016-03-25
Publication date: 2016-08-10

Abstract

An embodiment of the invention discloses an electronic medical record filing management system and an electronic medical record filing management method. The electronic medical record filing management system comprises the components of a medical record generating server, an inspection report generating server and a medical case generating server, wherein the medical record generating server is used for receiving the electronic medical record of a target patient and transmitting the electronic medical record of the target patient to the medical case generating server. The medical case generating server is used for receiving the electronic medical record of the target patient, wherein the electronic medical record of the target patient is transmitted by the medical record generating server. The medical case generating server transmits a searching request which aims at the inspection report of the target patient to the inspection report generating server, and receives the inspection report which returns from the inspection report generating server. The medical case generating server generates the electronic medical case of the target patient. The inspection report generating server is used for transmitting the searched inspection report to the medical case generating server. The electronic medical record filing management system provided by the embodiment of the invention does not require manual acquisition for the medical record and the inspection report of the target patient by personnel in a medical case room, thereby effectively reducing manpower and physical resource consumption and improving medical case filing efficiency.

Description

A kind of electronic health record archiving management system and method

Technical field

The present invention relates to Computer Applied Technology field, particularly to a kind of electronic health record archiving management system and Method.

Background technology

Medical record is the information material about patient health status, including sufferers themselves or other people subjectivity to the state of an illness Describe, medical worker to the audit report of patient, medical worker to the relative recording of conditions of patients and relevant There are the document of legal sense, document etc..

Traditional medical record filing typically refers to the filing to medical record physical property, i.e. to the recovery of cases history, Arrange, bind, number, filing etc..Handling after clearing of leaving hospital leave hospital patient, the physician of patient needs To complete patient's inpatient cases in 24 hours fills in work.Record room staff patrols receipts by checklist All section office upper one day discharged patients case history, verification patient's name and reclaim case history number of pages, to outpatient service receive Take the patient medical history before patient is in hospital, to each Medical Laboratory section office such as (check, check) electrocardiogram, pathology Collect the audit reports such as checklist, checklist, electrocardiogram, pathological replacement.Record room personnel arrange recovery Medical record, that reclaim by section office's registration and unrecovered medical record.

Traditional medical record archiving method is mainly by manually carrying out, and manpower and materials consume relatively big, and medical record is filed Inefficient.

Summary of the invention

The purpose of the embodiment of the present invention is to provide a kind of electronic health record archiving management system and method, with effectively Reduce manpower and materials consumption, improve medical record filing efficiency.Technical scheme is as follows:

A kind of electronic health record archiving management system, including: case history generates server, audit report generates service Device and medical record generation server, wherein,

Described case history generates server, for receiving the electronic health record of target patient, and by described target patient Electronic health record be sent to described medical record generate server；

Described medical record generates server, generates, for receiving described case history, the described target patient that server sends Electronic health record；Generate server to described audit report and send the audit report for described target patient Inquiry request, carries the identification information of described target patient, and receives described inspection in wherein said inquiry request Look into the audit report of the described target patient that report generation server returns；Generate the electronics of described target patient Medical record, comprises described electronic health record and audit report in wherein said electronic medical record；

Described audit report generates server, for receiving described medical record generation server for described mesh During the inquiry request of audit report of mark patient, search the audit report of described target patient and be sent to described Medical record generates server.

In a kind of detailed description of the invention of the present invention, described electronic health record archiving management system also includes medical record Storage server:

Described medical record generates server, also provides for inventory information and generates entrance, and receives Category-makers ' pair The inventory information that the electronic medical record of described target patient generates after carrying out list processing (LISP)；Extract described target patient The index information of electronic medical record；By sick for the electronics of the electronic medical record of described target patient, described target patient The inventory information of case and index information are sent to described medical record storage server；

Described medical record storage server, generates, for receiving and store described medical record, the described mesh that server sends Mark inventory information and the index information of the electronic medical record of the electronic medical record of patient, described target patient.

In a kind of detailed description of the invention of the present invention,

Described medical record storage server, is additionally operable to receive and store the signature document of described target patient and/or outer Institute's report scan part, or, receive and store the signature literary composition of the described target patient processed through digital signature Shelves and/or outer court's report scan part.

In a kind of detailed description of the invention of the present invention,

Described medical record generates server, specifically for being digitally signed the electronic medical record of described target patient Process, and the electronic medical record being digitally signed the described target patient of process is sent to the storage of described medical record Server.

In a kind of detailed description of the invention of the present invention, described electronic health record archiving management system also includes accessing Server:

Described access server, for receiving the applicant inquiry Shen for the electronic medical record of described target patient Please；According to default approval process, this inquiry application is sent to has examining of this electronic medical record power of examination and approval Criticize person；Receive the approval results that this inquiry is applied for by described approver；When described approval results is that examination & approval are passed through Time, the inquiry request of the electronic medical record for described target patient is sent to described medical record storage server, and The electronic medical record of the described target patient returned by described medical record storage server exports to described applicant；When When described approval results does not passes through for examination & approval, unsanctioned information is examined in output；

Described medical record storage server, is additionally operable to receive suffering from for described target of described access server transmission The inquiry request of the electronic medical record of person, and the electronic medical record of described target patient is returned to described access service Device.

In a kind of detailed description of the invention of the present invention,

Described medical record storage server, is additionally operable to recorded electronic medical record Query Information, and described electronic medical record is inquired about Information includes applicant's information, application time information, approver's information, examines temporal information, browses information In one or more.

A kind of electronic health record filing management method, including:

Case history generates server and receives the electronic health record of target patient, and by the electronic health record of described target patient It is sent to medical record and generates server；

Described medical record generates server and receives the electronics that described case history generates the described target patient of server transmission Case history；

Described medical record generates server and generates the server transmission inspection for described target patient to audit report The inquiry request of report, carries the identification information of described target patient in wherein said inquiry request；

Described audit report generates server and is receiving described medical record generation server for described target patient The inquiry request of audit report time, search the audit report of described target patient and to be sent to described medical record raw Become server；

Described medical record generates the described target patient of server reception described audit report generation server return Audit report；

Described medical record generates server and generates the electronic medical record of described target patient, in wherein said electronic medical record Comprise described electronic health record and audit report.

In a kind of detailed description of the invention of the present invention, described method also includes:

Described medical record generates server provides inventory information to generate entrance, and receives Category-makers ' to described target The inventory information that the electronic medical record of patient generates after carrying out list processing (LISP)；

Described medical record generates the index information that server extracts the electronic medical record of described target patient；

Described medical record generates server by sick for the electronics of the electronic medical record of described target patient, described target patient The inventory information of case and index information are sent to medical record storage server；

Described medical record storage server receives and stores described medical record and generates the described target patient that server sends Electronic medical record, the inventory information of electronic medical record of described target patient and index information.

Described medical record storage server receives and stores the signature document of described target patient and/or outer court reports and sweeps Retouch part, or, receive and store the signature document of the described target patient processed through digital signature and/or outer Institute's report scan part.

In a kind of detailed description of the invention of the present invention, described medical record generates server by described target patient Electronic medical record, the inventory information of electronic medical record of described target patient and index information are sent to medical record storage clothes Business device, including:

Described medical record generates server and the electronic medical record of described target patient is digitally signed process, and will It is digitally signed the volume of the electronic medical record of the electronic medical record of the described target patient of process, described target patient Mesh information and index information are sent to medical record storage server.

Access server and receive applicant's inquiry application for the electronic medical record of described target patient；

This inquiry application, according to the approval process preset, is sent to have this electronics sick by described access server The approver of the case power of examination and approval；

Described access server receives the approval results that this inquiry is applied for by described approver；When described examination & approval knot Fruit for examination & approval by time, send the electronic medical record for described target patient to described medical record storage server Inquiry request；When described approval results does not passes through for examination & approval, unsanctioned information is examined in output；

Described medical record storage server receives the electronics for described target patient that described access server sends The inquiry request of medical record, and the electronic medical record of described target patient is returned to described access server；

Described access server is by defeated for the electronic medical record of the described target patient that described medical record storage server returns Go out to described applicant.

Described medical record storage server record electronic medical record Query Information, described electronic medical record Query Information includes Applicant's information, application time information, approver's information, examine temporal information, the one browsing in information Or it is multiple.

The electronic health record archiving management system that the application embodiment of the present invention is provided, medical record generates server and receives Generate the electronic health record of the target patient that server sends to case history after, server can be generated to audit report Send the inquiry request of the audit report for target patient, and Receiving Inspection Report generates what server returned The coherence check report of this target patient, medical record generates server and according to the electronic health record of target patient and is correlated with Audit report, can automatically generate the electronic medical record of this target patient, it is not necessary to Record room staff pass through Artificially collect case history and the audit report of target patient, effectively reduce manpower and materials consumption, improve medical record Filing efficiency.

Accompanying drawing explanation

In order to be illustrated more clearly that the embodiment of the present invention or technical scheme of the prior art, below will be to enforcement In example or description of the prior art, the required accompanying drawing used is briefly described, it should be apparent that, describe below In accompanying drawing be only some embodiments of the present invention, for those of ordinary skill in the art, do not paying On the premise of going out creative work, it is also possible to obtain other accompanying drawing according to these accompanying drawings.

Fig. 1 is a kind of structural representation of electronic health record archiving management system in the embodiment of the present invention；

Fig. 2 is the another kind of structural representation of electronic health record archiving management system in the embodiment of the present invention；

Fig. 3 is a kind of implementing procedure figure of electronic health record filing management method in the embodiment of the present invention；

Fig. 4 is electronic health record archiving management system software architecture structural representation in the embodiment of the present invention；

Fig. 5 is the structural representation that in the embodiment of the present invention, electronic health record archiving management system comprises subsystem.

Detailed description of the invention

For the technical scheme making those skilled in the art be more fully understood that in the embodiment of the present invention, below will knot Close the accompanying drawing in the embodiment of the present invention, the technical scheme in the embodiment of the present invention is clearly and completely retouched State, it is clear that described embodiment is only a part of embodiment of the present invention rather than whole embodiments. Based on the embodiment in the present invention, those of ordinary skill in the art are institute under not making creative work premise The every other embodiment obtained, broadly falls into the scope of protection of the invention.

Shown in Figure 1, by the structure of a kind of electronic health record archiving management system that the embodiment of the present invention is provided Schematic diagram, this system can include that case history generates server 110, audit report generates server 120 and medical record Generation server 130, wherein,

Described case history generates server 110, for receiving the electronic health record of target patient, and described target is suffered from The electronic health record of person is sent to described medical record and generates server 130；

Described medical record generates server 130, generates, for receiving described case history, the described mesh that server 110 sends The electronic health record of mark patient；Generate server 120 to described audit report and send the inspection for described target patient Look into the inquiry request of report, wherein said inquiry request is carried the identification information of described target patient, and connects Receive described audit report and generate the audit report of the described target patient that server 120 returns；Generate described target The electronic medical record of patient, comprises described electronic health record and audit report in wherein said electronic medical record；

Described audit report generate server 120, for receive described medical record generate server 130 for During the inquiry request of the audit report of described target patient, search the audit report of described target patient and send Server 130 is generated to described medical record.

In embodiments of the present invention, target patient is any one inpatient of hospital, and different time is admitted to hospital Same patient can be considered different target patient.After target patient has handled Discharge, this target patient Physician the electronic health record of this target patient can be uploaded to case history generate server 110, trigger for The filing of the electronic medical record of this target patient.

In actual applications, in the target patient while in hospital, its physician can be sick by the electronics of hospital Go through editing machine and write the electronic health record of this target patient.After target patient has handled Discharge, this supervisor The electronic health record of this target patient can be uploaded to case history and generate server 110 by doctor.

Case history generates server 110 and the electronic health record of the target patient received is sent to medical record generation service Device 130, it is achieved the recovery of electronic health record, and trigger medical record generate server 130 collect each of this target patient Plant the operation of audit report.Medical record generates server 130 and receives the target that case history generation server 110 sends After the electronic health record of patient, it is possible to use the electronic health record of target patient is generated PDF by virtual printing technology File.

It is understood that target patient is in the while in hospital, various inspection may be done in relevant Medical Laboratory, Such as B ultrasonic, X-ray, electrocardiogram, electroencephalogram, sugar sieve, blood sample inspection, pathological analysis etc., each medical technologies The audit report of target patient can be uploaded to audit report and generate server 120 by desk work personnel.So, Medical record generate server 130 receive case history generate server 110 send target patient electronic health record after, Server 120 can be generated to audit report and send the inquiry request for this target patient, inquiry request is taken With the identification information of target patient, to inquire about the various audit reports of target patient.The mark letter of target patient Breath is the information that can uniquely identify this target patient, e.g., can be the numbering of being in hospital of target patient, or The identification information that the name of target patient, identification card number, hospital stays etc. combine.

After audit report generation server 120 receives inquiry request, if self storage has this target patient Audit report, then be sent to medical record by coherence check report and generate server 130.Medical record generates server 130 Utilize virtual printing technology that each audit report of target patient can generate the file of PDF.

In actual applications, can be that each Medical Laboratory of hospital is equipped with audit report generation server 120, Medical record generation server 130, can be respectively to each Medical Laboratory when needing the audit report inquiring about target patient Audit report generate server 120 send the inquiry request for target patient, the inspection report of each Medical Laboratory After announcement generation server 120 receives inquiry request, whether inquiry this locality exists the coherence check of this target patient Report, if it is present the coherence check inquired report can be sent to medical record to generate server 130, If it does not exist, then any operation can not be done, or generate server 130 to medical record and return and do not inquire phase Close the response message of audit report.

So, medical record generates server 130 can obtain electronic health record and the coherence check report of target patient, Such that it is able to these files are arranged according to default order, generate the electronic medical record of this target patient, Realize the automatic archiving of the electronic medical record of target patient.The electronic health record comprised in this electronic medical record and various phase Close the file that audit report can be all PDF.

Shown in Figure 2, in one embodiment of the invention, this electronic health record archiving management system is all right Including medical record storage server 140:

Described medical record generates server 130, also provides for inventory information and generates entrance, and receives Category-makers ' The inventory information generated after the electronic medical record of described target patient is carried out list processing (LISP)；Extract described target to suffer from The index information of the electronic medical record of person；By the electronic medical record of described target patient, the electronics of described target patient The inventory information of medical record and index information are sent to described medical record storage server 140；

Described medical record storage server 140, generates what server 130 sent for receiving and store described medical record The electronic medical record of described target patient, the inventory information of electronic medical record of described target patient and index information.

After medical record generates the electronic medical record that server 130 generates target patient, the electricity of this target patient can be extracted Essential information in sub-medical record, disease surgery information etc., and these information are supplied to Category-makers ', it is provided that Inventory information generates entrance, by Category-makers ' according to the keyword comprised in disease surgery information, according to presetting Rule, the electronic medical record of target patient is carried out list processing (LISP), generates inventory information.Meanwhile, medical record is raw Server 130 is become to may be provided for quick ICD (International Classification of Diseases, international disease Sick classification) code lookup, auxiliary Category-makers ' carries out list processing (LISP).

Meanwhile, medical record generates the index information that server 130 could extract and set up the electronic medical record of target patient. In actual applications, as long as the information relevant to the electronic medical record of target patient all can be as its index letter Breath, as medical record information (name of target patient, sex, date of birth etc.), diagnosis information (are admitted to hospital Section office, physician, main suit, doctor's advice, diagnosis etc.), medical expense information (total cost, nurse fees etc.), Surgical diagnosis inventory information etc..

Medical record generates server 130 to be believed the cataloguing of the electronic medical record of target patient, the electronic medical record of target patient Breath and index information are sent to medical record storage server 140.Medical record storage server 140 receives and stores medical record Generate server 130 send the electronic medical record of target patient, target patient electronic medical record inventory information and Index information.Concrete, medical record generates server 130 can also carry out numeral by the electronic medical record of target patient Signature processes, and the electronic medical record being digitally signed the target patient of process is sent to medical record storage service Device 140.The electronic medical record of the target patient that medical record storage server 140 receives is for having carried out at digital signature The electronic medical record of reason.

In actual applications, medical record storage server 140 can include file child servers and data base's sub-services Device.File child servers is for storing the electronic medical record of target patient, and database subsystem server is used for storing mesh The inventory information of the electronic medical record of mark patient and index information.

Wherein, each document that in file child servers, electronic medical record is comprised can be pdf document.For file Child servers, it is possible to use FTP technology, encrypts FTP path, carries out double copies and processes to ensure that document will not Lose, and solve the high availability problem of the long-term operation of storage service.Document storage organization can be year-moon- Day-the time.

Database subsystem server can solve based on Cach é data base and multiple load-balanced server integration The storage of high concurrent real time data and relevant query statistic business, such as the inquiry etc. of history medical record information.

In embodiments of the present invention, the electronic medical record generated in the nearest time period can be backed up at night Process, or as required some time period at one day carry out increment full backup process.For apart from current Electronic medical record remote can use tape library backup, returns in system when makeing mistakes or be to be used.Also That is, in hospital, the electronic medical record of all patients may be stored in the disk battle array of medical record storage server 140 In row, tape library and CD server.It can be made regular check on backup, it is ensured that the electronic medical record of filing Storage security, can meet case history long-term storage demand in 30 years.And, electronic medical record content will not sensitive paper Matter medical record is equally stained problem, it is ensured that the primitiveness of information, verity and law safety.

In actual applications, according to the requirement of hospital, some document needs patient to sign, such as Informed Consent Form Deng.It addition, patient in hospital time may carry outer court report.So, Record room staff can be by mesh The signature document of mark patient and/or outer court's report scan part upload to medical record storage server 140.For ensureing these The safety of document, these documents can also be uploaded after digital signature processes by Record room staff again Server 140 is stored to medical record.It is to say, medical record storage server 140 is additionally operable to receive and store target The signature document of patient and/or outer court's report scan part, or, receive and store through digital signature process The signature document of target patient and/or outer court's report scan part.Medical record storage server 140 receives these documents After, can be by these documentation to specifying position, for this mesh stored in medical record storage server 140 Document identical with the signature document of this target patient in the electronic medical record of mark patient, can directly do at replacement Reason.

In the electronic health record archiving management system that the embodiment of the present invention is provided, in medical record storage server 140 All kinds of documents in the electronic medical record of the target patient of storage can be the file of PDF.As such, it is possible to Make electronic health record archiving management system that the embodiment of the present invention provided independent of other operation systems of hospital, Can not rely in the operation systems such as HIS (Hospital Information System, hospital information system) Data, various course of disease file and image data, such that it is able to be prevented effectively from because the liter of hospital business system The generation of the situation about being difficult by of the electronic medical record content that level changes and causes, it is simple to electricity is constantly accumulated by hospital Sub-medical record assets.

Shown in Figure 2, in another embodiment of the present invention, electronic health record archiving management system is all right Including accessing server 150.

Described access server 150, for receiving applicant's inquiry for the electronic medical record of described target patient Application；According to default approval process, this inquiry application is sent to have this electronic medical record power of examination and approval Approver；Receive the approval results that this inquiry is applied for by described approver；When described approval results is logical for examination & approval Out-of-date, the inquiry request of the electronic medical record for described target patient is sent to described medical record storage server 140, And the electronic medical record that described medical record stores the described target patient that server 140 returns exports to described application Person；When described approval results does not passes through for examination & approval, unsanctioned information is examined in output；

Described medical record storage server 140, is additionally operable to receive that described access server 150 sends for described The inquiry request of the electronic medical record of target patient, and the electronic medical record of described target patient is returned to described visit Ask server 150.

In actual applications, medical treatment, research and teaching, public security organs' evidence obtaining, Hospital Accreditation, rational use of drug inspection, Monitoring of infection medical records etc. need, and have the query demand of the electronic medical record to patient.But, electronic medical record relates to And to patients ' privacy problem, and not all applicant can arbitrarily inquire about the electronic medical record of patient.So, The entity or individual of query demand is had to need submission to inquire about application accordingly the electronic medical record of patient.Application Person can send the electronic medical record for target patient by accessing server 150 to medical record storage server 140 Inquiry application.Concrete, applicant can input certain querying condition, medical record storage server 140 According to the index information of each electronic medical record determine applicant to be inquired about be the electronic medical record of which patient.

Access server 150 receive applicant for the inquiry request of the electronic medical record of target patient after, permissible According to default approval process, this inquiry application is sent to the approver with this electronic medical record power of examination and approval.

Pass through if the approval results that this inquiry is applied for by approver is examination & approval, then accessing server 150 can be to Medical record storage server 140 sends the inquiry request of the electronic medical record for target patient, medical record storage server After 140 receive this inquiry request, return to the electronic medical record found access server 150.Access clothes Medical record is stored the electronic medical record that server 140 returns and exports to applicant by business device 150.

If the approval results that this inquiry is applied for by approver does not passes through for examination & approval, then access server 150 permissible Export the unsanctioned information of examination & approval to user, this information can also include examining do not pass through reason Etc. information.

It addition, medical record storage server 140 may be provided for printing interface.When receiving access server 150 After the inquiry request of the electronic medical record of target patient is found this electronic medical record, lead to if receiving applicant Cross and access the print command that server 150 sends, then can complete the printing of the electronic medical record to this target patient, So can reduce the labor intensity of Record room staff.

In another embodiment of the present invention, medical record storage server 140 can be also used for recorded electronic medical record Query Information, described electronic medical record Query Information includes applicant's information, application time information, approver's letter One or more cease, examine temporal information, browsed in information.

The electronic medical record Query Information that medical record storage server 140 is recorded can be consulted for high authority user, enters And sensitive medical record can be safeguarded, it is further ensured that the confidentiality of electronic medical record.

It addition, in the case of carrying out needing hospital to provide electronic medical record during settlement of insurance claim after target patient is left hospital, The family members of target patient or target patient can provide the identity document of target patient, Record room management personnel The electronic medical record of this target patient can be searched in medical record storage server 140 by accessing server 150, And the identity document of target patient scanned the appointment position uploading to medical record storage server 140, print with should The medical record file relevant to insurance reimbursement of target patient.

The electronic health record archiving management system that the hospital application embodiment of the present invention is provided, it is possible to achieve with patient Centered by electronic medical record concentration filing, store and manage, it is possible to achieve electronic medical record inquiry examination & approval electricity Sonization, reduces the dependency to original, provides for hospital's sustained improvement Level of Medical Record Management and supports.Meanwhile, Can also pass through sharing of real-time performance electronic medical record, a electronic medical record can be borrowed by many people inquiry simultaneously, Improve electronic medical record resource utilization.

Corresponding to the system above embodiment, the embodiment of the present invention additionally provides a kind of electronic health record filing management Method, shown in Figure 3, the method may comprise steps of:

S310: case history generates server and receives the electronic health record of target patient, and by the electricity of described target patient Sub-case history is sent to medical record and generates server.

In embodiments of the present invention, target patient is any one inpatient of hospital, and different time is admitted to hospital Same patient can be considered different target patient.After target patient has handled Discharge, this target patient Physician the electronic health record of this target patient can be uploaded to case history generate server, trigger for this The filing of the electronic medical record of target patient.

In actual applications, in the target patient while in hospital, its physician can be sick by the electronics of hospital Go through editing machine and write the electronic health record of this target patient.After target patient has handled Discharge, this supervisor The electronic health record of this target patient can be uploaded to case history and generate server by doctor.

After case history generates the electronic health record that server receives target patient, by the electronic health record of this target patient It is sent to medical record and generates server, it is achieved the recovery of electronic health record.

S320: described medical record generates server and receives the described target patient that described case history generation server sends Electronic health record.

Medical record generates server and receives the electronic health record that case history generates the target patient of server transmission, and triggers It collects the operation of various audit reports of this target patient.Medical record generates server can utilize virtual printing The electronic health record of target patient is generated the file of PDF by technology.

S330: described medical record generates server and generates server transmission for described target patient to audit report The inquiry request of audit report, wherein said inquiry request is carried the identification information of described target patient.

It is understood that target patient is in the while in hospital, various inspection may be done in relevant Medical Laboratory, Such as Electrocardioscopy, blood sample inspection, pathological analysis etc., each Medical Laboratory staff can be by target The audit report of patient is uploaded to audit report and generates server.

In actual applications, can be that each Medical Laboratory of hospital configures same audit report generation server, Each Medical Laboratory will be uploaded to this audit report generation server to the audit report of target patient, it is also possible to for One audit report of each Medical Laboratory assignment configuration of hospital generates server, and target will be suffered from by each Medical Laboratory The audit report of person is uploaded to corresponding audit report and generates server.

Medical record generate server receive case history generate server send target patient electronic health record after, Server can be generated to audit report and send the inquiry request for this target patient, inquiry request is carried The identification information of target patient, to inquire about the various audit reports of target patient.The identification information of target patient For can uniquely identify the information of this target patient, e.g., can be the numbering of being in hospital of target patient, or mesh The identification information of the combinations such as the mark name of patient, identification card number, hospital stays.

S340: described audit report generates server and is receiving described medical record generation server for described mesh During the inquiry request of audit report of mark patient, search the audit report of described target patient and be sent to described Medical record generates server.

Medical record generates whether server exists the phase of target patient according to the inquiry request received, inquiry this locality Close audit report, if it is present the coherence check inquired report can be sent to medical record to generate service Device, if it does not exist, then any operation can not be done, or does not inquires to medical record generation server return The response message of coherence check report.

S350: described medical record generates server and receives the described target that described audit report generation server returns The audit report of patient.

Medical record generates server can generate the coherence check of the target patient that server returns with Receiving Inspection Report Report.Medical record generates server and virtual printing technology can also be utilized each audit report of target patient to be generated The file of PDF.

S360: described medical record generates server and generates the electronic medical record of described target patient, wherein said electronics Medical record comprises described electronic health record and audit report.

After medical record generates electronic health record and the coherence check report that server obtains target patient, can be according in advance If order these files are arranged, generate the electronic medical record of this target patient, it is achieved target patient The automatic archiving of electronic medical record.The electronic health record comprised in this electronic medical record and the report of various coherence check Think the file of PDF.

The method that the application embodiment of the present invention is provided, medical record generates server and receives case history generation server After the electronic health record of the target patient sent, server can be generated to audit report and send for target patient The inquiry request of audit report, and Receiving Inspection Report generates the relevant of this target patient that server returns Audit report, medical record generates server and reports according to electronic health record and the coherence check of target patient, can be certainly The dynamic electronic medical record generating this target patient, it is not necessary to Record room staff is by artificially collecting target patient Case history and audit report, relative to traditional medical record archiving method, effectively reduce manpower and materials consumption, Improve medical record filing efficiency.

In one embodiment of the invention, described method can also comprise the following steps:

Step one: described medical record generates server provides inventory information to generate entrance, and receives Category-makers ' pair The inventory information that the electronic medical record of described target patient generates after carrying out list processing (LISP)；

Step 2: described medical record generates the index information that server extracts the electronic medical record of described target patient；

Step 3: described medical record generates server by the electronic medical record of described target patient, described target patient The inventory information of electronic medical record and index information be sent to medical record storage server；

Step 4: described medical record storage server receives and stores described medical record and generates the described of server transmission The electronic medical record of target patient, the inventory information of electronic medical record of described target patient and index information.

For convenience of describing, aforementioned four step is combined and illustrates.

After medical record generates the electronic medical record that server generates target patient, the electronics of this target patient can be extracted Essential information in medical record, disease surgery information etc., and these information are supplied to Category-makers ', it is provided that compile Mesh information generates entrance, by Category-makers ' according to the keyword comprised in disease surgery information, according to default Rule, carries out list processing (LISP) to the electronic medical record of target patient, generates inventory information.Medical record generates server 0 May be provided for quick ICD code to search, auxiliary Category-makers ' carries out list processing (LISP).

Meanwhile, medical record generates the index information that server could extract and set up the electronic medical record of target patient. In actual applications, as long as the information relevant to the electronic medical record of target patient all can be as its index letter Breath, as medical record information (name of target patient, sex, date of birth etc.), diagnosis information (are admitted to hospital Section office, physician, main suit, doctor's advice, diagnosis etc.), medical expense information (total cost, nurse fees etc.), Surgical diagnosis inventory information etc..

Medical record generates server by the electronic medical record of target patient, the inventory information of the electronic medical record of target patient And index information is sent to medical record storage server.Medical record storage server receives and stores medical record and generates service The electronic medical record of target patient, the inventory information of the electronic medical record of target patient and the index information that device sends. Concrete, medical record generates server can also be digitally signed process to the electronic medical record of target patient, and The inventory information of the electronic medical record of the electronic medical record of the target patient of process, target patient will be digitally signed And index information is sent to medical record storage server.The electronics of the target patient that medical record storage server receives Medical record is the electronic medical record being digitally signed process.

In actual applications, medical record storage server can include file child servers and data base's child servers. The electronic medical record of file child servers storage target patient, the electronics of database subsystem server storage target patient The inventory information of medical record and index information.

In embodiments of the present invention, in hospital, the electronic medical record of all patients may be stored in medical record storage clothes In the business disk array of device, tape library and CD server.It can be made regular check on backup, it is ensured that filing The storage security of electronic medical record, case history long-term storage demand in 30 years can be met.And, electronic medical record Content will not equally be stained problem by sensitive paper matter medical record, it is ensured that the primitiveness of information, verity and law Safety.

In another embodiment of the present invention, described method can also comprise the following steps:

In actual applications, according to the requirement of hospital, some document needs patient to sign, such as Informed Consent Form Deng.It addition, patient in hospital time may carry outer court report.So, Record room staff can be by mesh The signature document of mark patient and/or outer court's report scan part upload to medical record storage server.For ensureing these literary compositions The safety of shelves, these documents can also be uploaded to after digital signature processes by Record room staff again Medical record storage server.It is to say, medical record storage server can receive and store the signature of target patient Document and/or outer court's report scan part, or, receive and store the target patient processed through digital signature Signature document and/or outer court's report scan part.

After medical record storage server receives these documents, can be right by these documentation to specifying position In the electronic medical record of this target patient stored in medical record stores server, the signature with this target patient is civilian The document that shelves are identical, can directly do replacement and process.

First step: access server and receive applicant's inquiry for the electronic medical record of described target patient Application；

Second step: this inquiry application, according to the approval process preset, is sent to by described access server There is the approver of this electronic medical record power of examination and approval；

3rd step: described access server receives the approval results that this inquiry is applied for by described approver； When described approval results for examination & approval by time, to described medical record storage server send for described target patient The inquiry request of electronic medical record；When described approval results does not passes through for examination & approval, output examination & approval are unsanctioned Information；

4th step: described medical record storage server receive described access server send for described mesh The inquiry request of the electronic medical record of mark patient, and the electronic medical record of described target patient is returned to described access Server；

5th step: the described target patient that described medical record storage server is returned by described access server Electronic medical record export to described applicant.

For convenience of describing, above-mentioned five steps are combined and illustrates.

In actual applications, medical treatment, research and teaching, public security organs' evidence obtaining, Hospital Accreditation, rational use of drug inspection, Monitoring of infection medical records etc. need, and have the query demand of the electronic medical record to patient.But, electronic medical record relates to And to patients ' privacy problem, and not all applicant can arbitrarily inquire about the electronic medical record of patient.So, The entity or individual of query demand is had to need submission to inquire about application accordingly the electronic medical record of patient.Application Person can send the inquiry of the electronic medical record for target patient by accessing server to medical record storage server Application.Concrete, applicant can input certain querying condition, and medical record storage server is according to each electronics The index information of medical record determine applicant to be inquired about be the electronic medical record of which patient.

Access server receive applicant for the inquiry request of the electronic medical record of target patient after, Ke Yigen According to default approval process, this inquiry application is sent to the approver with this electronic medical record power of examination and approval.

Pass through if the approval results that this inquiry is applied for by approver is examination & approval, then accessing server can be to disease Case storage server sends the inquiry request of the electronic medical record for target patient, and medical record storage server receives After this inquiry request, return to the electronic medical record found access server.Access server by medical record The electronic medical record that storage server returns exports to applicant.

If the approval results that this inquiry is applied for by approver does not passes through for examination & approval, then accessing server can be to User exports the unsanctioned information of examination & approval, can also include examining not by reason etc. in this information Information.

In embodiments of the present invention, described medical record storage server can be with recorded electronic medical record Query Information, institute State electronic medical record Query Information and include applicant's information, application time information, approver's information, examination & approval time Information, one or more browsed in information.

The electronic medical record Query Information that medical record storage server is recorded can be consulted for high authority user, and then Sensitive medical record can be safeguarded, be further ensured that the confidentiality of electronic medical record.

Electronic health record archiving management system and method that the embodiment of the present invention is provided specifically can pass through Fig. 4 institute The software architecture shown realizes, and this software architecture includes architecture layer, service layer, application layer and client layer.

Wherein, architecture layer mainly includes the infrastructure such as hardware, network, storage, and is that electronics is sick Go through archiving management system provide base support software module, concrete, including operating system, data base, Application server, LIST SERVER etc..

Service layer provides modular infrastructure service for electronic medical record filing, mainly includes scan service, content Management, safety management and the data-interface of other system, PDF service etc..The service implemented is as follows:

Operation system completes the concentration extraction of the data such as audit report by data/address bus, and combines PDF service Each audit report document is converted to PDF file, the electronic medical record generation module of application layer completes electricity The generation of sub-medical record.Or, each operation system completes the life of the document of respective content directly in conjunction with PDF service Become, by the electronic medical record generation module of application layer, each document is concentrated, generate electronic medical record；

Scan service can be that the papery medical record scan module of application layer provides interface, supports papery scanned copy Filing management；

Content Management can be that the medical record circulation control module of application layer provides interface, supports that electronic medical record is static The longer-term storage of document and utilization；

Safety management refers to the document security empowerment management of electronic medical record, supports medical record circulation control modular service What related procedure related to utilizes security certificate when electronic medical record, filing electronic medical record to manage.

Application layer realizes the application service that medical record filing is relevant, specifically includes:

Electronic medical record generation module is reclaimed action triggers by the case history of medical record circulation control module, and combines data Interface carries out integrity, consistency desired result；

Papery medical record scan module can call the scan service of service layer, and papery medical record scan module can be by The case history of medical record circulation control module reclaims action triggers, it is possible to directly triggered by scanning client；

Disease, Operation encoding module can be automatically performed coded data in conjunction with data-interface and initialize, and reduces and compiles Mesh person works's intensity；

Medical record circulation control module can carry out case history recovery, check, catalogue, file added, borrow, sick All workflow managements such as case duplicating, and relative recording form can be provided.Returning of medical record circulation control module Shelves are added, borrow, copying medical records function need to be called the content management service of service layer and complete.Medical record circulates Management module comprises the key message of patient, and the content management service collaborative offer patient critical letter of service layer The index of breath and inquiry；

Module consulted by medical record and Case analysis module can be called after the content management service of service layer completes to authorize Medical record consult and analyze.

Shown in Figure 5, to distinguish from functional perspective, the electronic health record archiving management system shown in Fig. 2 is permissible Including five subsystems: electronic medical record generates subsystem, medical record catalogue management subsystem, medical record circulation control Subsystem, filing medical record retrieval subsystem and filing medical record browse subsystem.Wherein, electronic medical record generates son System can include that case history generates server, audit report generates server and the part of medical record generation server Module, medical record catalogue management subsystem can include that medical record generates the part of module of server, medical record runner pipe Reason subsystem can include that medical record generates the part of module of server, filing medical record retrieval subsystem and filing disease Case browses subsystem and may each comprise medical record storage server and access server.

The electronic health record archiving management system provided the embodiment of the present invention from each subsystem angle below is carried out Explanation.

(1) electronic medical record generates subsystem

Electronic medical record generates subsystem, is the basis of whole electronic health record archiving management system application, the most first Collect electronic medical record relevant documentation to store together and can carry out later stage application.

Electronic medical record generates subsystem and includes two modules:

1, electronic health record automatically generates pdf document and collects module；

2, papery medical record is scanned into pdf document and collects module.

Wherein, electronic health record automatically generates pdf document and collects module, can be raw by the electronic health record of patient Become the document of PDF, and arrange in a designated order.Electronic health record prints based on PDF virtual machine and generates Pdf document, it is not necessary to transformation subservice system, or can obtain original in the case of transformation amount is less Electronic health record.

Electronic health record generates pdf document and has following three kinds of interface modes:

Interface mode one: by standard print interface, the printing interface generating routine call document to be collected enters Row virtual printing becomes pdf document.

Interface mode two: downloaded by FTP, the download from the FTP appointing position of generation program has been The document to be collected of PDF.

Interface mode three: Webservice is issued, and generates the Webservice that routine call document to be collected is issued Interface acquisition document or document flow reconvert become the document of PDF.

Certain time point after patient discharge, this time point can configure according to practical situation and change, Such as doctor letter of confirmation writes electronic health record, and nurse confirms patient discharge and finishes final clearing etc., by patient This time diagnosis information add queue to be generated.Queue scheduling submodule can by the highest for queue medium priority just The information of examining distributes to an idle dummy activity center, and dummy activity center starts according to the life being pre-configured with One-tenth scheme, calls above-mentioned interface mode successively and calls total interface and carry out the generation of PDF document.Generating knot The unified archive file storehouse that uploads to after bundle, and extract corresponding information to filing index database (registration patient assessment master Index and set up other indexes), the generation completing this medical PDF document collects.

Electronic health record automatically generates the generation event of pdf document and is divided into two classes: a class is normal generation；Another Class is the generation of abnormal conditions occur.

Electronic health record automatically generates pdf document and an automatic regular polling thread can be used to realize.This thread is not Disconnected poll queue to be generated, it is determined whether there is a need to the record generated.In view of systematic function, and actual make Situation, each poll find do not need generate record, then strengthen the interval of each poll, until Reach the maximum (interval of each poll and the maximum at interval can configure) arranged.Medical record generates submodule If block gets record from queue to be generated, just this record is moved to generate queue, when record starts Between, then start to generate.For the abnormal process generated, then be check continually on whether generation queue has super Time record, if it has, then take over this record, the generation time is rewritten, and by the priority of this record Fall one-level.When priority is preferably minimized grade, program is not reprocessed, outputting alarm information, waits hand inspection Process.

When electronic health record generation pdf document has generated, first check for the time started of record, if with Current task is consistent, as it is possible that the generation time has exceeded the time-out time of configuration, but now abnormal raw One-tenth processes and has taken over this record, so the file generated specifically should be abandoned.After inspection is complete, Need generation files passe to repositories of documents, and move to generate successfully from generating queue by generation record Queue.

It can in addition contain appointment patient's identification number, file in emergency circumstances needing the medical record generated in time.

Papery medical record is scanned into pdf document and collects module, patient can be signed document, outer by scanning Institute's report etc. is scanned into the file of standard PDF.Patient's document of signing can include all kinds of Informed Consent Form Etc. the document needing patient or family numbers of patients to sign.

It is by driving scanner or high photographing instrument that papery medical record is scanned into pdf document, obtains papery medical record Scanned picture, and picture is converted to pdf document.In actual applications, can be manually to the PDF generated File is classified, it is also possible to by agreement, print on patient signs document, outer court's report scan part The Quick Response Code that patient's medical record is relevant, during picture is converted to pdf document, by specifying region It is analyzed, obtains the information in Quick Response Code, automatically it is classified.

It addition, according to the requirement of hospital, patient may need to sign in the case history printed, but Owing to medical record generation module is automatically case history all to be generated, without skipping those pages needing signature, Now, it is necessary to by the pdf document of scanning, replace specific page.Without the part replaced then directly on Pass to specify position.

Papery medical record is scanned into pdf document and to collect the interface mode of module can be standard scanner interface.

Go to a doctor it should be noted that logically can automatically collect this with once medical scanned document In all generation projects.

(2) medical record catalogue management subsystem

Medical record catalogue management subsystem comprises two modules:

1, medical record information management module；

2, medical record cataloguing code management module.

Wherein, medical record information manages module by medical record information from EMR (Electronic Medical Record, electronic health record) system extracts and structured storage is in medical record catalogue management subsystem, for Filing medical record retrieval subsystem provides data basis.

Medical record cataloguing code management module extracts the information such as the disease in electronic medical record, operation, carries out ICD Coding.

(3) medical record circulation control subsystem

Medical record circulation control subsystem comprises with lower module:

1, filing patient information management module；

2, medical record flow-through operation module；

3, history medical record typing module.

Wherein, filing patient information management module management has filed patient basis, for the medical record each ring of circulation Joint and filing medical record retrieval subsystem provide data basis.Filing patient information management module by data/address bus Integrated platform obtains patient information, and in electronic health record archiving management system, electronic medical record has been concentrated, and certain is suffered from All diagnosis information of person all collect under the electronic medical record of this patient, collect the basic letter of all discharged patients Breath, diagnosis information, inventory information, cost information also set up index to inquire about and adding up.

The medical record intermediate links such as medical record flow-through operation module carries out that medical record filing is added, borrows, duplicates, outbound Management, wherein medical record-lending management submodule, medical record go out library management submodule is filing medical record based on authority Browse subsystem and part permissions data is provided.One added flow process of complete electronic medical record filing is as follows:

This flow process almost relate to all subsystems of electronic health record archiving management system, by flexible, easy Management means, can effectively reduce the labor intensity of Record room staff.Before case history reclaims, logical Cross case history Quality Control quantized data verifying work；Automatically the essential information with managing patient is collected by data/address bus (in independent index database, storing and set up the index of these information), and can carry out more with HIS data in real time New verification；Pdf document can be generated by one-key operation electronic health record, and be uploaded to Content Management System；Electronics is sick Go through generation pdf document and use PDF virtual printer exactly, by the platform of electronic health record archiving management system, The particular virtual archiving services of each subservice system is called, according to clinical history information according to arrangements Format print generates pdf document, preserves after arranging medical record information and processing these document classifications, Complete electronic medical record filing to submit to.Automatically disease and the operation information of first page of illness case is collected by data/address bus, Carry out medical record list processing (LISP).Finally electronic medical record is filed added.

Electronic medical record can be borrowed by many people simultaneously, only need to complete to borrow registration and examination & approval, and doctor can be in section Room browses subsystem by filing medical record and browses and file medical record.If it exceeds medical record-lending time limit, Borrowing right Limit automatically retracts.

The electronic health record archiving management system of the embodiment of the present invention can provide the printing function of filing electronic medical record. In order to protect the lawful right of patient, prevent unauthorized personnel from printing electronic medical record, carry out illegal behavior. Print electronic medical record by strict control.Only there is print right and have the people side of hardware keys simultaneously Electronic medical record can be printed.Simultaneity factor can be complete the print log of recorded electronic medical record, including electronic medical record Printing content and quantity, and the printing applicant of paper-based medical record, the certificate photo of applicant, and by these Information is stored in archiving server, in order to follow the tracks of the whereabouts of these electronic medical records being printed as paper.

History medical record typing module supports history medical record typing.

(4) filing medical record retrieval subsystem

Filing medical record retrieval subsystem provides medical record search function based on rights management.Search condition can be Patient basis, medical record information or disease and operation inventory information, concrete, can be patient ID, patient's name, admission number, date of birth, be in hospital section office, hospital stays, section office of leaving hospital, when leaving hospital Between, the doctor in charge, discharge diagnosis etc..

For more complicated research and development management retrieval etc., retrieval can be completed by research data management system, and Browse subsystem with filing medical record to integrate, check filing medical record.According to various search conditions, applicant is permissible Quickly navigate to the electronic medical record needed.

Patient files electronic medical record carry out concentration and browse and file, some related to including Patients ' Electronic medical record The report of special format.After obtaining corresponding report process control and relevant interface, PDF is utilized to read These reports can completely be consulted by instrument.

(5) filing medical record browses subsystem

Applicant browses subsystem by filing medical record can be to by filing what medical record retrieval subsystem retrieved Content browses.

It should be noted that in this article, the relational terms of such as first and second or the like be used merely to by One entity or operation separate with another entity or operating space, and not necessarily require or imply these Relation or the order of any this reality is there is between entity or operation.And, term " includes ", " bag Contain " or its any other variant be intended to comprising of nonexcludability, so that include a series of key element Process, method, article or equipment not only include those key elements, but also include being not expressly set out Other key elements, or also include the key element intrinsic for this process, method, article or equipment.? In the case of there is no more restriction, statement " including ... " key element limited, it is not excluded that at bag Include and the process of described key element, method, article or equipment there is also other identical element.

Each embodiment in this specification all uses relevant mode to describe, phase homophase between each embodiment As part see mutually, what each embodiment stressed is the difference with other embodiments. For device embodiment, owing to it is substantially similar to embodiment of the method, so the comparison described Simply, relevant part sees the part of embodiment of the method and illustrates.

One of ordinary skill in the art will appreciate that all or part of step realizing in said method embodiment The program that can be by completes to instruct relevant hardware, and described program can be stored in computer-readable Take in storage medium, the storage medium obtained designated herein, such as: ROM/RAM, magnetic disc, CD etc..

The foregoing is only presently preferred embodiments of the present invention, be not intended to limit protection scope of the present invention. All any modification, equivalent substitution and improvement etc. made within the spirit and principles in the present invention, are all contained in In protection scope of the present invention.

Claims

1. an electronic health record archiving management system, it is characterised in that including: case history generates server, inspection Look into report generation server and medical record and generate server, wherein,

Electronic health record archiving management system the most according to claim 1, it is characterised in that described electronics Case history archiving management system also include medical record store server:

Electronic health record archiving management system the most according to claim 2, it is characterised in that

5. according to the electronic health record archiving management system described in any one of claim 2 to 4, it is characterised in that Described electronic health record archiving management system also include access server:

Electronic health record archiving management system the most according to claim 5, it is characterised in that

7. an electronic health record filing management method, it is characterised in that including:

Method the most according to claim 7, it is characterised in that described method also includes:

Method the most according to claim 8, it is characterised in that described method also includes:

Method the most according to claim 8, it is characterised in that described medical record generates server by described The electronic medical record of target patient, the inventory information of electronic medical record of described target patient and index information are sent to Medical record storage server, including:

11. according to Claim 8 to the method described in 10 any one, it is characterised in that described method also includes:

12. methods according to claim 11, it is characterised in that described method also includes: