CN106372455B - A kind of hospital's medical record writing quality control system and method - Google Patents
A kind of hospital's medical record writing quality control system and method Download PDFInfo
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- CN106372455B CN106372455B CN201611076652.9A CN201611076652A CN106372455B CN 106372455 B CN106372455 B CN 106372455B CN 201611076652 A CN201611076652 A CN 201611076652A CN 106372455 B CN106372455 B CN 106372455B
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- G—PHYSICS
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- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H40/00—ICT specially adapted for the management or administration of healthcare resources or facilities; ICT specially adapted for the management or operation of medical equipment or devices
- G16H40/20—ICT specially adapted for the management or administration of healthcare resources or facilities; ICT specially adapted for the management or operation of medical equipment or devices for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
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- G—PHYSICS
- 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
A kind of hospital's medical record writing quality control system of present invention proposition and method, the system include case history input unit, host one, host two, host three and mobile phone；Host one, host two and host three are sequentially connected by Intranet special line, and host two is connect by wireless communication with case history input unit, and host two is connected by China Mobile network with mobile phone；The wherein described case history input unit is books shape, including microprocessor, memory, wireless network card, touch display screen and Fingerprint Identification Unit, microprocessor be connected with memory, wireless network card, touch display screen and Fingerprint Identification Unit respectively.Advantage of the invention is that system can effectively constrain the writing case history that doctor guarantees both quality and quantity by specification；Administrative department can conveniently configure, change Quality control rules, comply with the change request of policy；According to Quality Control problem existing for clinic, can analyze there are the reason of, convenient for reinforce doctor management.
Description
Technical field
The present invention relates to medical information technical field, specifically a kind of hospital's medical record writing quality control system and method.
Background technology
During the medical record writing of hospital, medical worker passes through interrogation, physical examination, auxiliary examination, diagnosis, treatment, nursing etc.
Curative activity obtains relevant information, is analyzed one by one with regard to patient's different problems using problem guidance mode, and concluded, arranged
The curative activity of formation records, and each diagnosis and treatment are passed through, no matter outpatient service, emergency treatment and inpatient must record in detail examine reason,
Cardinal symptom, recently variation and medical treatment result, all diagnosis, the various facts treated should all be full and accurate according to time-series
It is recorded in case history, record all should write the time exactly and be signed by attending physician every time；Medical Dispute Prevention, case history are record diseases
Generation, evolution and Prognosis vital document, be medical worker objective, true, complete in diagnosis and treatment work
It record and summarizes, is quality of medical care technical merit, the foundation of management level overall merit, and solve medical tangle, into practising medicine
Treatment accident is identified, judges causal important evidence between medical worker's mistake and curative activity and Factual Damage.With society
The progress of meeting, people's life, the continuous improvement of educational level, legal conception, economic consciousness and self conservation concept
Constantly, there are higher requirement in enhancing, when patient assessment to quality of medical care, nursing quality, service quality, so, further specification
The writing of case history is especially important.Case history is portion of the medical staff in diagnostic work record and summary comprehensively.It was both to determine
Diagnosis and the foundation for formulating treatment and prevention measure, and summarize medical experience, enrich the content of courses and carry out the important of scientific research
Data, while it also has important legal basis, especially《Medical mishandling requlations》After issuing and implementation, clear stipulaties are suffered from
Person has the right to duplicate or replicate medical history record, also can be used as the foundation of doctor and patient proof.But there are still all in current medical record writing
More problems, it is possible to become the hidden danger of medical tangle；Case history has become one of most important foundation in Malpractice lawsuit, also just means
Each word in case history, each symbol represents a legal liabilities, and every words may all be used as legal basis, while disease
It goes through and is a double-edged sword, one side specification medical record writing can change the situation for lifting evidence of not coming to testify, be played to medical staff
Protective effect；But it if working not in place or cannot find change of illness state in time, affects treatment or rescue opportunity adversely, has caused to suffer from
Person's damage to person, same objectively medical history record is also the foundation for protecting patient's legitimate rights and interests；Therefore, medical record writing code requirement
It is increasingly stringenter, it is desirable that doctor increasingly specification, new Quality control rules should be conducive to the medical treatment text of specification doctor when writing case history
Book writes behavior, and new rule is set according to new demand convenient for administrative department, and carries out clinical quality monitoring work.Currently,
The medical record writing system of existing hospital, has the following defects：1) in medical record writing system operation procedure, clinician is sometimes
This clinic behaviour lack of standardization cannot timely and effectively be supervised or be prevented to the writing case history on time that cannot be guaranteed both quality and quantity, subsequent Quality Control
Make, preferably administrative department cannot be helped to achieve the purpose that quality monitoring；2) medical record writing system forces control dependent on program
Quality control rules, autgmentability is poor, according to medical record writing specification, when there is new rule to put into effect, in order to increase new Quality control rules,
It needs to change program code, and issues new version so that administrative department cannot conveniently configure new Quality control rules；Flexibly
Property it is poor, when meta-rule changes, system will also do corresponding modification of program so that rule change it is time-consuming and laborious；
Therefore, a kind of hospital's medical record writing quality control system and method are researched and developed, needs to solve following technical problem：1) how to have
Effect ensure write case history in real time；2) how effectively to ensure that medical record writing is not changed arbitrarily；3) how easily to increase disease
The primary attribute gone through；4) Quality control rules of case history how easily to be configured；5) how to ensure the accuracy of the real-time Quality Control of case history；
Structuring, templating writing and the new Quality control rules of case history are conducive to the medical document writing line of specification doctor
To set new rule according to new demand convenient for administrative department, and carry out clinical quality monitoring work；To these technical problems
Tackling key problem and solution be the research and development of current medical information technical field one of emphasis direction.
Invention content
In view of the drawbacks of the prior art, a kind of hospital's medical record writing quality control system provided by the invention and method, realization be
When medical record writing and supervision doctor write document quality, conveniently configure, safeguard Quality control rules, periodically dissect hospital
Medical record writing there are the problem of；Purpose to realize the present invention, the technical scheme is that：
The first aspect of the invention provides a kind of hospital's medical record writing quality control system, including：Case history input unit, master
Machine one, host two, host three and mobile phone；Host one, host two and host three are sequentially connected by Intranet special line, and host two passes through
Wireless communication is connect with case history input unit, and host two is connected by China Mobile network with mobile phone；The wherein described case history
Input unit is books shape, including microprocessor, memory, wireless network card, touch display screen and Fingerprint Identification Unit, microprocessor
Device is connected with memory, wireless network card, touch display screen and Fingerprint Identification Unit respectively, and microprocessor, memory, wireless network card are set
It sets in the inside of case history input unit, touch display screen is arranged in the front of case history input unit, and Fingerprint Identification Unit is arranged in disease
Go through the back side of input unit；
Further, the host one is equipped with basic database, and the host two is provided with electronic health record application journey
Sequence server-side, the host three are provided with electronic health record database, pass through internal network between host one, host two and host three
Agreement ICP/IP protocol transmits data；
Further, the microprocessor includes medical record templates unit and case history lock cell；Medical record templates unit provides
Medical record writing template, case history lock cell lock writing and modification to case history under certain condition；
Further, the case history input unit is also overleaf provided with camera, can to the disease sites of patient into
Row is taken pictures or is imaged and records preservation；
Further, the case history input unit is additionally provided with the printing equipment of wireless connection, and printing behaviour is carried out to case history
Make；
Further, the case history input unit is additionally provided with infra-red ray body temperature device and pulse measurer, Ke Yixian
The body temperature and pulse information of field acquisition patient simultaneously store；
The operation principle and main process of this system are：Host one, host two and host three are respectively intended to installation data
Center, that is, UIS databases, electronic health record application program service end, that is, EMR server, electronic health record database, that is, EMR data library；
Data are transmitted by internal network protocol, that is, ICP/IP protocol between three hosts, are passed through between case history input unit and host two
It is then by two end routine call China Mobile MAS gateways of host for short message sending that WebService, which carries out data interaction,
Corresponding short message content is sent the user mobile phone pre-set by WebService.In host two and mobile MASS gateways and
It is designed with fire wall between outer net, safety is improved with this, reduces the risk attacked by outer net.
In case history input unit, microprocessor is for managing the operation of case history input unit and data processing, including case history mould
Plate unit and case history lock cell；Medical record templates unit writes case history using the template of structuring, and template is divided into full institute's Universal Die
Plate and training personalized template, all templates are encoded according to certain coding rule, form a unique template code.
In newly-increased training personalized template, it is necessary to select a template as caster from full institute, training subtemplate is inherited out with this.
In this way, when setting mass controlled template to Quality control rules, rule supervision is exactly a class template, rather than a specific template.
In order to ensure the implementation effect of real-time Quality Control function, when doctor completes medical record document not within the specification time, microprocessor
The patient history can be lockked, the writing or modification which cannot be continued；It needs doctor to submit application, is examined through department of medical administration
Writing document is can continue after case history unlock；This effectively can supervise doctor to write case history in time.
In case history input unit, memory to carry out electronic health record information and run program storage；Microprocessor
PORT COM is connect with wireless network card, for carrying out long-range data exchange with host two；Touch display screen is located at case history input
The front end of device, to show output case history module and write input medical record information, finishing man-machine interaction process；Pass through fingerprint
The identity of doctor is identified in identifier, writing and modification authority of the setting medical staff to case history, in order to writing disease
Confirmation and the specification of medical staff's main body are gone through, convenient for the examination to doctor's quality of case history；
During medical record writing, for enabled Quality control rules, host two can configure in extracting rule pre- system
Alert information judged, when reaching early warning line, host two sends Quality Control short message to related doctor to pre-setting automatically
Doctor's mobile phone, reminds which part document of which patient of doctor will offend which Quality Control item at what time, asks doctor complete as early as possible
At related document；If doctor does not complete related document in time yet more than the Quality Control time limit, case history input unit can be by patient's disease
Locking is gone through, doctor will be unable to write to appoint to patient to watch document, it is necessary to by doctor's submission system application, after being audited by department of medical administration, case history
Doctor can just continue to write document to patient after unlock.
The second aspect of the invention is to provide a kind of method of hospital's medical record writing Quality Control, includes the following steps：
Step 1, doctor write input case history；Doctor carries out the writing and input of case history by case history input unit, first
Then doctor carries out human-computer interaction, typing case history, and case history is protected by Fingerprint Identification Unit login system by touch display screen
It deposits and by wireless network transmissions to host two；
Step 2, manager configure Quality Control formula；It is completed by hospital's medical record writing quality control system, first, defining matter
Primary attribute is controlled, certain methods can be defined from the data center in host one to extract attribute needed for Quality Control, second, host two will
Patient attribute group builds up Quality Control formula, the allocation formula by the way of natural language, the setting deduction of points mark when configuring Quality control rules
Accurate, warning information and Quality control rules enabling state；Third, host two configures mass controlled template；
Step 3, hospital's medical record writing quality control system enable Quality control rules；For enabled Quality control rules, system can carry
The warning information configured in rule is taken to be judged, when reaching early warning line, system sends Quality Control short message to related doctor automatically
It to mobile phone, reminds which part document of which patient of doctor will offend which Quality Control item at what time, doctor is asked to complete as early as possible
Related document；
Step 4, locking case history and unlock case history；If doctor does not complete related document in time yet more than the Quality Control time limit,
The case history input unit of system can will lock patient history, and doctor will be unable to write any document to patient, it is necessary to be submitted by doctor
System application, after being audited by department of medical administration, manager is unlocked case history by hospital's medical record writing quality control system, and doctor just can be after
Continue and write document to patient, is stored in host three after case history qualification.
The main operational principle of this method is：(1) in order to ensure the implementation effect of real-time Quality Control function, when doctor does not exist
When completing document by medical record writing device in the specification time, system can lock the patient history, and doctor is needed to submit application, warp
Writing document is can continue after department of medical administration examination ＆ approval；Increase approval process and great resistance is brought to the writing document lack of standardization of doctor
Hinder, effectively doctor can be supervised to write case history in time；In addition, Quality Control function can link with performance appraisal in real time, it more can be effective
Supervise what doctor guaranteed both quality and quantity to be timely completed corresponding document；(2) the primary attribute data in real-time Quality Control function are realized in system
The UIS data centers for deriving from host one, define different methods, for extracting different attribute datas, pass through
The mode of WebService is transmitted to the Emr systems of host two, is used for real-time Quality Control function；When needing to increase new primary attribute
When, it is only necessary to a new method is defined, Webservice interfaces are updated；(3) efficiently configuration Quality Control is advised for convenience
Then, this system develop it is being configured based on natural formula, can foreground safeguard Quality control rules configuration feature；The function uses nature
The combination of formula builds up primary attribute group needed for Quality Control, and one semanteme of formation is clearly understandable, safeguards and convenient
Efficiently Quality control rules；(4) in order to ensure the accuracy of real-time Quality Control, this system is all using the template of structuring writing disease
It goes through；Template is divided into full institute's common template and training personalized template, and all templates are encoded according to certain coding rule, shape
At a unique template code.In newly-increased training personalized template, it is necessary to select a template as caster from full institute,
Training subtemplate is inherited out with this.In this way, when setting mass controlled template to Quality control rules, rule supervision is exactly a class template,
Rather than a specific template.
From the above technical solution of the present invention shows that, the present invention and traditional hospital's medical record writing quality control system and method phase
Than having the advantage that and beneficial effect：
(1) quality that doctor writes document can be supervised in real time；
(2) can with the configuration of more convenient and quicker, safeguard Quality control rules；
(3) clinician's application approval record lack of standardization for writing document can be recorded, is linked with bonus, attendance checking system,
Convenient for the examination to doctor's quality of case history；
(4) the higher Quality control rules of frequency and associated department can be offended with periodic analysis clinic, dissect hospital's medical record writing
There are the problem of, reinforce the management and construction of section office.
Description of the drawings
Fig. 1 is the system structure diagram of hospital's medical record writing quality control system embodiment of the present invention；Wherein：
1- case history input units；2- hosts one；3- hosts two；4- hosts three；5- mobile phones；6- Fingerprint Identification Units；7- is touched
Display screen；8- memories；9- wireless network cards；10- case history lock cells；11- medical record templates units；12- microprocessors.
Fig. 2 is the flow diagram of hospital's medical record writing quality control method embodiment of the present invention.
Specific implementation mode
In the following with reference to the drawings and specific embodiments, the present invention is furture elucidated；
If Fig. 1 shows, the first aspect of the invention, a kind of preferred embodiment of hospital's medical record writing quality control system, including：
Case history input unit 1, host 1, host 23, host 34 and mobile phone 5；Host 1, host 23 and host 34 pass through Intranet
Special line is sequentially connected, and host 23 is connect by wireless communication with case history input unit 1, and host 23 passes through China Mobile's net
Network is connected with mobile phone 5；The wherein described case history input unit 1 is books shape, including microprocessor 12, memory 8, wireless network card
9, touch display screen 7 and Fingerprint Identification Unit 6, microprocessor 12 respectively with memory 8, wireless network card 9, touch display screen 7 and refer to
Line identifier 6 is connected, and microprocessor 12, memory 8, wireless network card 9 are arranged in the inside of case history input unit 1, touch display
Screen 7 is arranged in the front of case history input unit 1, and Fingerprint Identification Unit 6 is arranged at the back side of case history input unit 1；
Further, the host 1 is equipped with basic database, and the host 23 is provided with electronic health record application
Procedure service end, the host 34 are provided with electronic health record database, by interior between host 1, host 23 and host 34
Portion's procotol ICP/IP protocol transmits data；
Further, the microprocessor 12 includes medical record templates unit 11 and case history lock cell 10；Medical record templates list
Member 11 provides medical record writing template, and case history lock cell 10 locks writing and modification to case history under certain condition；
Further, the case history input unit 1 is also overleaf provided with camera, can to the disease sites of patient into
Row is taken pictures or is imaged and records preservation；
Further, the case history input unit 1 is additionally provided with the printing equipment of wireless connection, and printing behaviour is carried out to case history
Make；
Further, the case history input unit 1 is additionally provided with infra-red ray body temperature device and pulse measurer, Ke Yixian
The body temperature and pulse information of field acquisition patient simultaneously store；
The operation principle and main process of this system are：Host one, host two and host three are respectively intended to installation data
Center, that is, UIS databases, electronic health record application program service end, that is, EMR server, electronic health record database, that is, EMR data library；
Data are transmitted by internal network protocol, that is, ICP/IP protocol between three hosts, are passed through between case history input unit and host two
It is then by two end routine call China Mobile MAS gateways of host for short message sending that WebService, which carries out data interaction,
Corresponding short message content is sent the user mobile phone pre-set by WebService.In host two and mobile MASS gateways and
It is designed with fire wall between outer net, safety is improved with this, reduces the risk attacked by outer net.
In case history input unit, microprocessor is for managing the operation of case history input unit and data processing, including case history mould
Plate unit and case history lock cell；Medical record templates unit writes case history using the template of structuring, and template is divided into full institute's Universal Die
Plate and training personalized template, all templates are encoded according to certain coding rule, form a unique template code.
In newly-increased training personalized template, it is necessary to select a template as caster from full institute, training subtemplate is inherited out with this.
In this way, when setting mass controlled template to Quality control rules, rule supervision is exactly a class template, rather than a specific template.
In order to ensure the implementation effect of real-time Quality Control function, when doctor completes medical record document not within the specification time, microprocessor
The patient history can be lockked, the writing or modification which cannot be continued；It needs doctor to submit application, is examined through department of medical administration
Writing document is can continue after case history unlock；This effectively can supervise doctor to write case history in time.
In case history input unit, memory to carry out electronic health record information and run program storage；Microprocessor
PORT COM is connect with wireless network card, for carrying out long-range data exchange with host two；Touch display screen is located at case history input
The front end of device, to show output case history module and write input medical record information, finishing man-machine interaction process；Pass through fingerprint
The identity of doctor is identified in identifier, writing and modification authority of the setting medical staff to case history, in order to writing disease
Confirmation and the specification of medical staff's main body are gone through, convenient for the examination to doctor's quality of case history；
During medical record writing, for enabled Quality control rules, host two can configure in extracting rule pre- system
Alert information judged, when reaching early warning line, host two sends Quality Control short message to related doctor to pre-setting automatically
Doctor's mobile phone, reminds which part document of which patient of doctor will offend which Quality Control item at what time, asks doctor complete as early as possible
At related document；If doctor does not complete related document in time yet more than the Quality Control time limit, case history input unit can be by patient's disease
Locking is gone through, doctor will be unable to write any document to patient, it is necessary to by doctor's submission system application, after being audited by department of medical administration, case history
Doctor can just continue to write document to patient after unlock.
As shown in Fig. 2, the second aspect of the invention is to provide a kind of hospital's medical record writing quality control method, including following step
Suddenly：
S01, doctor write input case history；Doctor carries out the writing and input of case history by case history input unit, cures first
It is raw to pass through Fingerprint Identification Unit login system, human-computer interaction, typing case history are then carried out by touch display screen, and case history is preserved
With pass through wireless network transmissions to host two；
S02, manager configure Quality Control formula；It is completed by hospital's medical record writing quality control system；
First, defining Quality Control primary attribute, certain methods can be defined from the data center in host one to extract Quality Control institute
Attribute is needed, such as patient admission time, discharge time, operation time started, blood transfusion time etc..Quality Control function passes through webservice
Interface mode reads patient's Quality Control attribute；
Second, patient attribute group is built up Quality Control formula by host two, the allocation formula by the way of natural language, such as Quality Control
Rule " record of being admitted to hospital need to be completed to examine label (cure mainly and the above doctor) in 72 hours after patient admission ", can advise Quality Control according to semanteme
Then it is configured to following formula：" enter area's time<>Empty And current times-enter area time ＜=72；Examine the areas Qian Shijian-Ru time ＜
=72；Examine label rank ＞=attending physician's audit "；When configuring Quality control rules, can set standard of deducting point, warning information and
The enabling state of Quality control rules；
Third, host two configures mass controlled template, since the template in system is there are inheritance, template coding has
Certain rule；Such as, the template code of the general admission records of full institute is " 10.0001. ", inherits subtemplate out for first part and compiles
Code is " 10.0001.0001. ", and so on；As " record of being admitted to hospital need to be completed to examine label in 72 hours after patient admission Quality control rules
(cure mainly and the above doctor) ", for the mass controlled template set as general admission records, Quality Control project supervision is a class template, that is,
System judge clinician whether by specification completion be admitted to hospital record when, complete no matter doctor is with the document of institute template writing, still
The document write with training template, is all the document for meeting Quality control rules；
S03, hospital's medical record writing quality control system enable Quality control rules；For enabled Quality control rules, system can be extracted
The warning information configured in rule is judged, when reaching early warning line, system sent automatically to related doctor Quality Control short message to
Mobile phone, reminds which part document of which patient of doctor will offend which Quality Control item at what time, and doctor is asked to complete phase as early as possible
Close document；
S04, locking case history and unlock case history；If doctor does not complete related document in time yet more than the Quality Control time limit, it is
The case history input unit of system can will lock patient history, and doctor will be unable to write any document to patient, it is necessary to submit system by doctor
System application, after being audited by department of medical administration, manager is unlocked case history by system, and doctor can just continue to write document to patient,
It is stored in after case history qualification in host three.
The main operational principle of this method is：(1) in order to ensure the implementation effect of real-time Quality Control function, when doctor does not exist
When completing document by medical record writing device in the specification time, system can lock the patient history, and doctor is needed to submit application, warp
Writing document is can continue after department of medical administration examination ＆ approval；Increase approval process and great resistance is brought to the writing document lack of standardization of doctor
Hinder, effectively doctor can be supervised to write case history in time；In addition, Quality Control function can link with performance appraisal in real time, it more can be effective
Supervise what doctor guaranteed both quality and quantity to be timely completed corresponding document；(2) the primary attribute data in real-time Quality Control function are realized in system
The UIS data centers for deriving from host one, define different methods, for extracting different attribute datas, pass through
The mode of WebService is transmitted to the Emr systems of host two, is used for real-time Quality Control function；When needing to increase new primary attribute
When, it is only necessary to a new method is defined, Webservice interfaces are updated；(3) efficiently configuration Quality Control is advised for convenience
Then, this system develop it is being configured based on natural formula, can foreground safeguard Quality control rules configuration feature；The function uses nature
The combination of formula builds up primary attribute group needed for Quality Control, and one semanteme of formation is clearly understandable, safeguards and convenient
Efficiently Quality control rules；(4) in order to ensure the accuracy of real-time Quality Control, this system is all using the template of structuring writing disease
It goes through；Template is divided into full institute's common template and training personalized template, and all templates are encoded according to certain coding rule, shape
At a unique template code.In newly-increased training personalized template, it is necessary to select a template as caster from full institute,
Training subtemplate is inherited out with this.In this way, when setting mass controlled template to Quality control rules, rule supervision is exactly a class template,
Rather than a specific template.
In conclusion a kind of hospital's medical record writing quality control system and method for the present embodiment have various advantages, it can
Effectively to constrain doctor, the writing case history guaranteed both quality and quantity by specification；With the change of medical record writing code requirement, administrative department
It can conveniently configure, change Quality control rules, comply with the change request of policy；It, can according to Quality Control problem existing for clinic
With analysis there are the reason of, convenient for reinforcing section office and personal management.
Description above word and attached drawing are only explanation and illustration of the invention and explanation, are not constituted in any form to the present invention
Limitation and limit, the scope of the present invention is subject to claims, all without departing from present inventive concept it is obvious change,
Transformation and alternative solution are within the scope of the present invention.
Claims (1)
1. a kind of hospital's medical record writing quality control method, which is characterized in that include the following steps：
Step 1, doctor write input case history；Doctor carries out the writing and input of case history, first doctor by case history input unit
By Fingerprint Identification Unit login system, then by touch display screen carry out human-computer interaction, typing case history, and by case history preserve and
Pass through wireless network transmissions to host two；
Step 2, manager configure Quality Control formula；It is completed by hospital's medical record writing quality control system, first, defining Quality Control base
Plinth attribute can define certain methods to extract attribute needed for Quality Control from the data center in host one, second, host two is by patient
Set of properties builds up Quality Control formula, the allocation formula by the way of natural language, and standard of deducting point, pre- is set when configuring Quality control rules
The enabling state of alert information and Quality control rules；Third, host two configures mass controlled template；
The mass controlled template includes full institute's common template and training personalized template, all templates according to certain coding rule into
Row coding, in newly-increased training personalized template, it is necessary to select a template as caster from full institute, training is inherited out with this
Personalized subtemplate；
Step 3, hospital's medical record writing quality control system enable Quality control rules；For enabled Quality control rules, system can extract rule
The warning information configured in then is judged that, when reaching early warning line, it is in one's hands that system sends Quality Control short message to related doctor automatically
Machine, reminds which part document of which patient of doctor will offend which Quality Control item at what time, and doctor is asked to complete correlation as early as possible
Document；
Step 4, locking case history and unlock case history；If doctor does not complete related document, system in time yet more than the Quality Control time limit
Case history input unit can will lock patient history, doctor will be unable to write any document to patient, it is necessary to by doctor's submission system
Application, after being audited by department of medical administration, manager is unlocked case history by hospital's medical record writing quality control system, doctor can just continue to
Patient writes document, is stored in host three after case history qualification.
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| CN108511045A (en) * | 2017-10-24 | 2018-09-07 | 姬广敬 | A kind of hospital care Management of quality control control system and application method |
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| CN109829696B (en) * | 2019-01-28 | 2021-06-15 | 中钞信用卡产业发展有限公司杭州区块链技术研究院 | Block chain-based electronic license management method, device, equipment and medium |
| CN110034939A (en) * | 2019-04-04 | 2019-07-19 | 旭辉卓越健康信息科技有限公司 | A kind of AI medical treatment all-in-one machine having communication control function |
| CN110808089B (en) * | 2019-10-16 | 2022-04-01 | 云知声智能科技股份有限公司 | Method and device for displaying defect number under document catalog |
| CN111739599B (en) * | 2020-06-19 | 2023-08-08 | 北京嘉和海森健康科技有限公司 | Teaching medical record generation method and device |
| CN112992306B (en) * | 2021-04-30 | 2021-08-24 | 四川省肿瘤医院 | Method and system for improving efficiency of acquiring medical records of discharge hospital |
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