CN107391933A - A kind of electronic health record quality control management device and method - Google Patents
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Abstract
The present invention proposes a kind of electronic health record quality control management device and method, and the device includes：Electronic health record collecting unit, electronic health record data resolution unit, link Quality Control unit and Online QC unit；Wherein, electronic health record collecting unit is used to gather electronic health record data message；Electronic health record data resolution unit is used to parse the data message, and carries out quality control to electronic health record for analysis result；Link Quality Control unit is used for the quality examination to having completed electronic health record；Online QC unit is used for the quality examination to electronic health record in completion.The present invention occurs diagnosis and treatment event-monitoring progress medical record writing for patient and given a previous notice, case history Quality control rules inspecting in process is carried out during medical record writing to remind, complete to carry out case history postmortem and scoring in quality control process in medical record writing, reflect the quality condition of electronic health record in time.
Description
Technical Field
The invention belongs to the technical field of informatization of medical systems, and particularly relates to a quality control management device and method for an electronic medical record.
Background
The medical record is the summary of experience of a doctor flexibly applying medical knowledge in a long-term clinical practice process, objectively and completely records the change of the state of an illness of a patient and the whole process of diagnosis and treatment, and is the sum of data such as characters, charts, images, slices and the like formed by medical staff in the process of medical activities. Nowadays, with the increasingly developed information technology, electronic medical record systems are gradually popularized in hospitals at all levels, and compared with the traditional paper medical records, the electronic medical records have the characteristics of convenience in writing, convenience in interaction, flexibility in access and the like, the electronic medical records are convenient for medical staff to write and query, the working efficiency is improved, some medical record quality problems are shown, and the electronic medical record systems become important components of medical quality management. With the deep application of the electronic medical records, a new platform is provided for medical record quality control, and the real-time quality control of the electronic medical records becomes possible, namely how to manage the quality of the electronic medical records becomes a new subject of a hospital quality management department.
At present, the function of the electronic medical record quality control system has great limitation. The quality control doctor who is specially responsible for the quality control of the medical records still needs to evaluate and check the medical records filled by the clinician manually, so that the quality control flow efficiency is low, the processing process is delayed, and the quality condition of the medical records cannot be reflected in time.
Based on the above, the electronic medical record quality control management device and method provided by the invention automatically analyze the quality control scoring standard and the quality control rule through the embedded online quality control engine, perform medical record writing advance reminding aiming at the diagnosis and treatment event monitoring of the patient, perform medical record quality control rule check reminding in the medical record writing process, perform medical record post-event check and scoring in the quality control process after the medical record writing is completed, and reflect the quality condition of the electronic medical record in time.
Disclosure of Invention
The technical scheme provided by the invention for solving the technical problems is as follows:
the invention provides an electronic medical record quality control and management device, which comprises: the system comprises an electronic medical record acquisition unit, an electronic medical record data analysis unit, a link quality control unit and an online quality control unit; the electronic medical record acquisition unit is used for acquiring data information of the electronic medical record; the electronic medical record data analysis unit is used for analyzing the data information and controlling the quality of the electronic medical record according to the analysis result; the link quality control unit is used for performing quality inspection on the finished electronic medical records and comprises a medical record spot inspection module, a spot inspection grading module and a spot inspection result feedback module; the online quality control unit is used for quality inspection of the completed electronic medical record and comprises a rule analysis module, a task allocation module and an operation inspection module.
Furthermore, the medical record spot check module is used for extracting the finished electronic medical record by utilizing the preset query conditions of the device and corresponding spot check rule conditions set by a doctor; the spot check scoring module is used for automatically carrying out rule check and scoring on the extracted electronic medical record document according to the post quality control rule; and the spot check result feedback module is used for automatically feeding back the defect problems found by the spot check to the doctor to which the medical record belongs and informing the doctor to correct and modify the medical record of the corresponding defect problems.
Furthermore, the rule analysis module is used for analyzing and operating the quality control rules in advance and in advance; the task allocation module is used for triggering the corresponding advanced quality control rule in time and generating an advanced quality control task to remind a doctor according to the occurrence of relevant events for diagnosis and treatment of the patient with the operating medical record; the operation checking module is used for automatically analyzing the content quality control rules and the business logic rules in the operation according to the online operation state of the operation medical record and carrying out rule checking and judgment so as to provide online prompt for doctors in the medical record writing process.
Furthermore, the quality inspection of the link quality control unit comprises medical record writing standard inspection and clinical diagnosis and treatment quality inspection, wherein the medical record writing standard inspection is used for judging whether the completion time, writing format paragraphs and used medical terms of the medical record accord with preset rules or not; the clinical diagnosis and treatment quality inspection comprises three-level ward inspection, informed consent, anesthesia visit, diagnosis and treatment, auxiliary inspection, and whether nosocomial infection and/or antibacterial drug use meet preset rules.
Further, the data information includes structured electronic medical record data and electronic medical record data in natural language.
The invention also provides an electronic medical record quality control and management method, which comprises the following steps:
the method comprises the following steps: collecting data information of the electronic medical record;
step two: analyzing the data information;
step three: extracting relevant information aiming at different data types;
step four: judging the state of the electronic medical record according to the related information;
step five: and controlling the quality of the electronic medical records according to the medical records in different states.
Further, the different data types in the third step include structured electronic medical record data and electronic medical record data in natural language.
Further, the electronic medical record is in a state including not in progress and completed in progress.
Further, the fifth step is specifically: if the electronic medical record is not in the running state, performing advanced quality control on the electronic medical record; if the electronic medical record is in the on-going state, performing on-going quality control on the electronic medical record; and if the electronic medical record is in the finished state, performing post quality control on the electronic medical record.
Further, the prior quality control includes: analyzing and operating the prior quality control rule; according to the occurrence of diagnosis and treatment related events of the patient with the operating medical record, triggering the corresponding advanced quality control rule in time and generating an advanced quality control task to remind a doctor;
further, the quality control in said matter comprises: according to the online operation state of the operating medical record, the content quality control rule and the business logic rule in the operation are automatically analyzed and the rule is verified and judged so as to provide online prompt for doctors in the process of writing the medical record.
Further, the post-hoc quality control includes: extracting the finished electronic medical records; automatically carrying out rule check and grading on the extracted electronic medical record document according to the post-affair quality control rule; and automatically feeding back the defect problems found by the spot check to the doctor to which the medical record belongs, and informing the doctor to correct and modify the medical record of the corresponding defect problems.
The invention has the advantages that: the method can control the quality of the electronic medical record in advance, in advance and after, has compatibility in processing the data information of the electronic medical record, can process the structured electronic medical record data and the electronic medical record data in natural language, and can reflect the quality of the electronic medical record in time.
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Various other advantages and benefits will become apparent to those of ordinary skill in the art upon reading the following detailed description of the preferred embodiments. The drawings are only for purposes of illustrating the preferred embodiments and are not to be construed as limiting the invention. Also, like reference numerals are used to refer to like parts throughout the drawings. In the drawings:
fig. 1 is a schematic structural diagram of an electronic medical record quality control management apparatus according to the present invention.
FIG. 2 is a flow chart of the method for quality control and management of electronic medical records according to the present invention.
Detailed Description
Exemplary embodiments of the present disclosure will be described in more detail below with reference to the accompanying drawings. While exemplary embodiments of the present disclosure are shown in the drawings, it should be understood that the present disclosure may be embodied in various forms and should not be limited to the embodiments set forth herein. Rather, these embodiments are provided so that this disclosure will be thorough and complete, and will fully convey the scope of the disclosure to those skilled in the art.
Fig. 1 is a schematic structural diagram of an electronic medical record quality control management apparatus according to the present invention. FIG. 2 is a flow chart of the method for quality control and management of electronic medical records according to the present invention. The following describes an embodiment of the present invention with reference to fig. 1 and 2.
As shown in fig. 1, an electronic medical record quality control management apparatus according to the present invention includes an electronic medical record acquisition unit, an electronic medical record data analysis unit, a link quality control unit, and an online quality control unit.
The electronic medical record acquisition unit is used for acquiring electronic medical record data.
The acquired electronic medical record data enter an electronic medical record data analysis unit, and the electronic medical record data analysis unit analyzes the acquired electronic medical record data to acquire the type of the data information. The electronic medical record data can be the data of a structured electronic medical record and can also be the electronic medical record data of natural language.
If the electronic medical record is the data of the structured electronic medical record, the electronic medical record data is a set of patient information in the structured electronic medical record with metadata, wherein the metadata specifically comprises symptom metadata, anatomical part metadata, time metadata, quantity metadata, logic judgment metadata and the like, and for example, "diarrhea" belongs to symptom metadata.
If the electronic medical record is electronic medical record data in natural language, the electronic medical record data is a set of patient information in the electronic medical record with chapters, and relevant information of the medical record can be acquired from the chapters by extracting keywords.
After the data information of the electronic medical record is acquired, the quality of the electronic medical record can be controlled.
According to the data information of the electronic medical record, the state of the electronic medical record can be judged, if the data information is complete, the electronic medical record is judged to be in a finished state, and the after-the-fact quality control of the medical record is started; if a certain module or all the modules in the data information are blank, judging that the electronic medical record or the part of the electronic medical record is in an unoperated state, and starting the prior quality control of the medical record; and if some or all of the data information is partial data, but is incomplete, judging that the electronic medical record or the part of the electronic medical record is in an ongoing state, and starting the in-process quality control of the medical record.
If the medical record is subjected to post quality control, a link quality control unit is started, and the link quality control unit comprises a medical record spot check module, a spot check grading module and a spot check result feedback module.
The medical record spot check module is used for extracting the finished electronic medical record by utilizing the preset query conditions of the device and the corresponding spot check rule conditions set by the doctor; the quality control doctor can firstly set corresponding spot check rule conditions by using some preset inquiry conditions, and then check out typical medical records in the hospital at present (such as the medical records of the current inpatient, the current operation patient, the critical medical patient, and the like). Before doctors need to go to each department below to examine and extract typical medical records, the medical records meeting the requirement of the link quality control spot check can be listed and recommended to quality control doctors through the spot check medical record query of the link quality control unit. And selecting a certain medical record from the corresponding medical record list for spot check inquiry by the quality control personnel, clicking to carry out spot check, and enabling the medical record to enter the medical record list for spot check. The quality control personnel can select a medical record in a certain spot check list, click a spot check button, enter a link quality control spot check medical record working interface, then, the user can click an electronic medical record document directory structure tree of the working interface to see the existing electronic medical record document of the medical record, and double click can call the medical record document to check.
The spot check scoring module is used for automatically carrying out rule check and scoring on the extracted electronic medical record document according to the post quality control rule; when medical record spot check is carried out, a quality control doctor can click a spot check scoring function provided by the module, a spot check scoring recording window is popped up, the module lists a defect scoring list according to medical record quality check scoring standards in the window, then the quality control doctor can input the defects found by spot check, and the defect listing system can automatically carry out rule check on corresponding medical record documents according to quality control rules and simultaneously list the found defects in the scoring list for the quality control doctor to refer. The quality control doctor can store, modify and delete the scoring contents. The link quality inspection comprises case history writing standard inspection and clinical diagnosis and treatment quality inspection. The medical record writing standard inspection can be carried out according to the medical record writing scoring standard for inspection and scoring; the clinical diagnosis and treatment examination mainly comprises three-level ward inspection, informed consent, anesthesia visit, diagnosis and treatment, auxiliary examination, nosocomial infection, antibacterial drug use and the like for spot check scoring.
And the spot check result feedback module is used for automatically feeding back the defect problems found by the spot check to the doctor to which the medical record belongs and informing the doctor to correct and modify the medical record of the corresponding defect problems. When the quality control doctor finishes the spot check of a certain medical record document, the quality control spot check scoring of the link is also finished. At this point the click spot check is complete. The module will place the sub-medical records into a history of a list of already spot-reviewed medical records. Meanwhile, the defect problems found by the spot check are automatically fed back to the doctor to which the medical record belongs, and the doctor is informed to correct and modify the medical record of the corresponding defect problems.
If the medical record is subjected to advance or in-advance quality control, an online quality control unit is started, and comprises a rule analysis module, a task allocation module and an operation inspection module.
The rule analysis module is used for analyzing and operating the quality control rules in advance and in the process;
the task allocation module is used for triggering the corresponding advanced quality control rule in time and generating an advanced quality control task to remind a doctor according to the occurrence of relevant events for diagnosis and treatment of the patient with the operating medical record; such as prompting the physician which items should be filled in, etc.
The operation checking module is used for automatically analyzing content quality control rules and business logic rules in the operation according to the online operation state of the operation medical record and carrying out rule verification and judgment so as to provide online prompt for doctors in the medical record writing process; such as giving prompt of relevant normative medical terms during writing medical records by doctors, or automatic correction, etc.
Based on the electronic medical record quality control management device and the method, medical record writing is reminded in advance aiming at the monitoring of the diagnosis and treatment events of the patient, medical record quality control rule checking and reminding are carried out in the medical record writing process, medical record post-inspection and scoring are carried out in the quality control process after the medical record writing is finished, the quality condition of the electronic medical record is reflected in time, the electronic medical record does not need to be a structured electronic medical record, the quality control management can be completed on the electronic medical record in natural language, and the system compatibility is good.
The above description is only for the preferred embodiment of the present invention, but the scope of the present invention is not limited thereto, and any changes or substitutions that can be easily conceived by those skilled in the art within the technical scope of the present invention are included in the scope of the present invention. Therefore, the protection scope of the present invention shall be subject to the protection scope of the appended claims.
Claims (10)
1. An electronic medical record quality control management device is characterized in that: the method comprises the following steps: the system comprises an electronic medical record acquisition unit, an electronic medical record data analysis unit, a link quality control unit and an online quality control unit; wherein,
the electronic medical record acquisition unit is used for acquiring data information of the electronic medical record;
the electronic medical record data analysis unit is used for analyzing the data information and controlling the quality of the electronic medical record according to the analysis result;
the link quality control unit is used for performing quality inspection on the finished electronic medical records and comprises a medical record spot inspection module, a spot inspection grading module and a spot inspection result feedback module;
the online quality control unit is used for quality inspection of the completed electronic medical record and comprises a rule analysis module, a task allocation module and an operation inspection module.
2. The electronic medical record quality control management device according to claim 1, wherein: wherein,
the medical record spot check module is used for extracting the finished electronic medical record by utilizing the preset query conditions of the device and corresponding spot check rule conditions set by a doctor;
the selective examination scoring module is used for automatically carrying out rule examination and scoring on the extracted electronic medical record document according to the post quality control rule;
and the spot check result feedback module is used for automatically feeding back the defect problems found by the spot check to the doctor to which the medical record belongs and informing the doctor to correct and modify the medical record of the corresponding defect problems.
3. The electronic medical record quality control management device according to claim 1, wherein: the rule analysis module is used for analyzing and operating quality control rules in advance and in advance;
the task allocation module is used for triggering the corresponding advanced quality control rule in time and generating an advanced quality control task to remind a doctor according to the occurrence of relevant events for diagnosis and treatment of patients with operational medical records;
the operation checking module is used for automatically analyzing content quality control rules and business logic rules in the operation according to the online operation state of the operation medical record and carrying out rule checking and judgment so as to provide online prompt for doctors in the medical record writing process.
4. The electronic medical record quality control and management device as claimed in claim 2, wherein: the quality inspection of the link quality control unit comprises medical record writing standard inspection and clinical diagnosis and treatment quality inspection, wherein,
the medical record writing standard check is used for judging whether the completion time, writing format paragraphs and used medical terms of the medical record meet preset rules or not;
the clinical diagnosis and treatment quality inspection comprises three-level ward inspection, informed consent, anesthesia visit, diagnosis and treatment, auxiliary inspection, and whether nosocomial infection and/or antibacterial drug use meet preset rules.
5. The electronic medical record quality control management device according to claim 1, wherein: the data information includes structured electronic medical record data and electronic medical record data in natural language.
6. A quality control and management method for electronic medical records is characterized in that: the method comprises the following steps:
the method comprises the following steps: collecting data information of the electronic medical record;
step two: analyzing the data information;
step three: extracting relevant information aiming at different data types;
step four: judging the state of the electronic medical record according to the related information;
step five: and controlling the quality of the electronic medical records according to the medical records in different states.
7. The method for quality control and management of electronic medical records of claim 6, wherein: the different data types in the third step comprise structured electronic medical record data and electronic medical record data in natural language.
8. The method for quality control and management of electronic medical records of claim 7, wherein: the state of the electronic medical record comprises that the electronic medical record is not processed and the electronic medical record is processed and neutralized.
9. The method for quality control and management of electronic medical records of claim 8, wherein: the fifth step is specifically as follows: if the electronic medical record is not in the running state, performing advanced quality control on the electronic medical record; if the electronic medical record is in the on-going state, performing on-going quality control on the electronic medical record; if the state of the electronic medical record is finished, performing post quality control on the electronic medical record; the prior quality control includes: analyzing and operating the prior quality control rule; according to the occurrence of diagnosis and treatment related events of the patient with the operating medical record, triggering the corresponding advanced quality control rule in time and generating an advanced quality control task to remind a doctor; according to the online operation state of the operating medical record, the content quality control rule and the business logic rule in the operation are automatically analyzed and the rule is verified and judged so as to provide online prompt for doctors in the process of writing the medical record.
10. The method for quality control and management of electronic medical records of claim 9, wherein: the posterior quality control comprises: extracting the finished electronic medical records; automatically carrying out rule check and grading on the extracted electronic medical record document according to the post-affair quality control rule; and automatically feeding back the defect problems found by the spot check to the doctor to which the medical record belongs, and informing the doctor to correct and modify the medical record of the corresponding defect problems.
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| CN108389606A (en) * | 2018-05-08 | 2018-08-10 | 灵玖中科软件（北京）有限公司 | A kind of the data quality control system and its control method of electronic medical record homepage |
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