CN107526919A - Operation report record system and its recording method based on structuring - Google Patents
Operation report record system and its recording method based on structuring Download PDFInfo
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- CN107526919A CN107526919A CN201710570938.0A CN201710570938A CN107526919A CN 107526919 A CN107526919 A CN 107526919A CN 201710570938 A CN201710570938 A CN 201710570938A CN 107526919 A CN107526919 A CN 107526919A
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Abstract
The invention provides a kind of operation based on structuring to report record system, including：Logging modle, including N number of operation format, according to the custom requirements of each operation format, the parameters of the operation format are configured in the form of structuring, and will individually be stored with each operation format postponed；The normal attribute for the operation that selecting module needs to record based on doctor, select operation format corresponding with the operation；Order module is ranked up, and its order is included on operation record interface according to the routine operation flow of the operation to the operation format after selection；Display module is handled structured parameter after the completion of doctor is the structured parameter editor for the operation format for all corresponding to the operation, generates natural language report, and automatically shown natural language report.The invention also discloses a kind of operation based on structuring to report recording method.The present invention improves the speed that doctor writes operation record report, and operation is more convenient.
Description
Technical field
The present invention relates to medical information field, and record system is reported more particularly, to a kind of operation based on structuring
And its recording method.
Background technology
With the development of information technology and the construction of medical information, present hospital is auxiliary using various information software
Help medical industry operating process, such as " HIS (hospital information management system) ", " EMR (electronic medical record system) ", " PACS (medical science
PACS Medical) ", " RIS (image information management system) " etc..
At present, information system is widely used in each medical institutions, but the record system of medical surgery report is not
It is more, such as, radiography operation, stent procedure, the record report system etc. of endoscopic surgery, to the note of medical surgery report
Record mode, existing application mode have two kinds, and a kind of mode is generally to rely on existing system, such as HIS, manual typing
Mode recorded, and be stored in the system, however, surgical procedure is divided into multiple links, can have not in each link
Same record form, and the partial content of some record forms several record links before being connected to, and often have repetition
Record form occur, sometimes some record forms can also majority be conventional result, the frequent Palingraphia operation record of doctor is this
The defects of mode be by then manual typing, and can when have repeated editor, input speed is slow, reduces the work effect of doctor
Rate, further, since being to rely on existing system, therefore it is unfavorable for inquiry of the doctor to historical record；Another recording mode is
Recorded by the form of report template, to accelerate editing speed, but the record content each performed the operation is also relatively more, and this is just
Waste doctor's a lot of times, in the case of inefficient, the effect of display is also bad, operation record content it is readable also very
Difference..
The content of the invention
In view of this, it is a primary object of the present invention to provide it is a kind of based on structuring operation report record system and its
Recording method, can solve the problem that doctor's typing operation record speed present in prior art cause slowly operating efficiency it is low, operation not
The problem of convenient, readable poor.
To reach above-mentioned purpose, the technical proposal of the invention is realized in this way：
On the one hand, the invention provides a kind of operation based on structuring to report record system, including logging modle, selection
Module, order module and display module, wherein, logging modle, it is connected with selecting module, including N number of operation format, for basis
The custom requirements of each operation format, configure the parameters of the operation format in the form of structuring, and by with postponing
Each operation format is individually stored；Selecting module, it is connected respectively with logging modle and order module, for being needed based on doctor
The normal attribute for the operation to be recorded, select operation format corresponding with the operation；Order module, respectively with selecting module and aobvious
Show that module is connected, for the routine operation flow according to the operation, the operation format after selection is ranked up, and by its order
It is shown on operation record interface；Display module, be connected with order module, in doctor the behaviour for all corresponding to the operation
After the completion of making the structured parameter editor that form is configured, the structured parameter after the completion of editor is handled, generates nature
Speech reporting, and natural language report is shown to client automatically.
Preferably, the system also includes：Add module, it is connected with logging modle, for when doctor is according to each operation
Actual demand, when one operation format of selection is added, the operation format is included in the most lower of operation record interface automatically
Side.
Preferably, the system also includes：Module is inserted, is connected with logging modle, for when doctor is according to each operation
Actual demand, when one operation format of selection is inserted, automatically by the top of the currently displayed operation format of the operation format.
Preferably, logging modle also includes deleting unit, the actual demand for doctor according to each operation, selects one
When operation format is deleted, the operation format is deleted on operation record interface automatically.
Preferably, the system also includes：Enquiry module, it is connected with display module, for the natural language inputted according to doctor
Speech inquiry data, the historical record needed for doctor is included in client.
On the other hand, present invention also offers a kind of operation based on structuring to report recording method, including：Logging modle
Including N number of operation format, according to the custom requirements of each operation format, each of the operation format is configured in the form of structuring
Individual parameter, and will individually be stored with each operation format postponed；The normal attribute for the operation for needing to record based on doctor,
Selecting module selects operation format corresponding with the operation；Order module is according to the routine operation flow of the operation, after selection
Operation format be ranked up, and by its order include on operation record interface；In doctor all corresponding to the operation
After the completion of the structured parameter editor that operation format is configured, display module to the structured parameter after the completion of editor at
Reason, natural language report is generated, and natural language report is shown to client automatically.
Preferably, this method also includes：When doctor is carried out according to the actual demand of each operation, one operation format of selection
During addition, the operation format is included the bottom at operation record interface by add module automatically.
Preferably, this method also includes：When doctor is carried out according to the actual demand of each operation, one operation format of selection
During insertion, insertion module is automatically by the top of the currently displayed operation format of the operation format.
Preferably, this method also includes：Doctor selects an operation format to be deleted according to the actual demand of each operation
Except when, the deletion unit in logging modle automatically deletes the operation format on operation record interface.
Preferably, this method also includes：The natural language querying data that enquiry module inputs according to doctor, by needed for doctor
Historical record be shown in client.
The technique effect of the present invention：
1. due to being provided with logging modle, selecting module and order module in the present invention, each operation in logging modle
Parameters involved by form, are all configured in the form of structuring, and are individually stored, and need writer in doctor
During art record report, selecting module then automatically chooses all operation formats corresponding to the operation, and order module is by root
The operation format order after selection is included on operation record interface according to the routine operation flow of the operation, doctor can basis
Actual flow, each operation format individually being edited, doctor only need to click parameters in each operation format,
The efficiency that doctor writes operation record report is greatly improved, and operation interface is directly perceived；Meanwhile it is also provided with showing in system
Show module, the structured parameter of each operation format after can doctor be edited carries out the generation of natural language, forms nature
Speech reporting, significantly increase the readability of report；
2. because the form of ownership in system is all to be configured and configure in a conventional mode, therefore due to the spy of some operation
Different property, doctor can add operation format at any time according to the needs of surgical procedure, and the add module in the system solves this
Problem, when doctor is according to the actual demand of each operation, when one operation format of selection is added, add module automatically should
Operation format is shown in the bottom at operation record interface, facilitates editor and modification of the doctor to record report of performing the operation；
3. because the form of ownership in system is all to be configured and configure in a conventional mode, therefore due to the spy of some operation
Different property, doctor can insert another operation format, system under some operation format at any time according to the needs of surgical procedure
In insertion module operation format selected by a doctor can be then automatically inserted into above the operation format, facilitate doctor
Raw operation, so that the view effect at operation record interface is obvious；
4. because the present invention is also provided with deleting unit, doctor can be deleted the operation format according to operation needs
Remove, the system is more beneficial for the operation of the editor of doctor, more hommization；
5. because the present invention is also provided with enquiry module, be able to will be cured according to the natural language querying data of doctor's input
Raw required historical record is shown in client, can reach accurate inquiry, facilitate access of doctor's later stage to operation record.
Brief description of the drawings
Accompanying drawing described herein is used for providing a further understanding of the present invention, forms the part of the application, this hair
Bright schematic description and description is used to explain the present invention, does not form inappropriate limitation of the present invention.In the accompanying drawings：
Fig. 1 shows the structural representation of the according to embodiments of the present invention one operation report record system based on structuring
Figure；
Fig. 2 shows that conduit arrival in record system is reported according to embodiments of the present invention one operation based on structuring
Operation format list schematic diagram；
Fig. 3, which is shown in the according to embodiments of the present invention one operation report record system based on structuring, is sent into sacculus
Operation format list schematic diagram；
Fig. 4 shows that the operation of medication in record system is reported according to embodiments of the present invention one operation based on structuring
Form list schematic diagram；
Fig. 5 shows that conduit is to right hat in the according to embodiments of the present invention one report record system of the operation based on structuring
Opening is treated and puts the operation record interface schematic diagram of support；
Fig. 6 shows that conduit is to left master in the according to embodiments of the present invention one report record system of the operation based on structuring
Dry opening is treated and puts the operation record interface schematic diagram of support；
Fig. 7 shows the structural representation of the according to embodiments of the present invention two operation report record system based on structuring
Figure；
Fig. 8 shows that according to embodiments of the present invention two operation based on structuring reports that add module exists in record system
Schematic diagram in operation record interface；
Fig. 9, which shows to add in the according to embodiments of the present invention two report record system of the operation based on structuring, is sent into ball
Operation record interface schematic diagram after capsule operation format；
Figure 10 shows the structural representation of the according to embodiments of the present invention three operation report record system based on structuring
Figure；
Figure 11, which is shown in the according to embodiments of the present invention three report record system of the operation based on structuring, inserts module
Schematic diagram in operation record interface；
Figure 12, which is shown in the according to embodiments of the present invention three report record system of the operation based on structuring, is being sent into branch
The operation record interface schematic diagram inserted before frame operation format after being sent into sacculus operation format；
Figure 13 shows the structural representation of the according to embodiments of the present invention four operation report record system based on structuring
Figure；
Figure 14, which is shown in the according to embodiments of the present invention four report record system of the operation based on structuring, deletes unit
Schematic diagram in operation record interface；
Figure 15 shows the structural representation of the according to embodiments of the present invention five operation report record system based on structuring
Figure；
Figure 16 shows the flow chart of the according to embodiments of the present invention six operation report recording method based on structuring；
Figure 17 shows that according to embodiments of the present invention six operation based on structuring reports that conduit reaches in recording method
Operation format list schematic diagram；
Figure 18, which is shown in the according to embodiments of the present invention six report recording method of the operation based on structuring, is sent into sacculus
Operation format list schematic diagram；
Figure 19 shows that the behaviour of medication in recording method is reported according to embodiments of the present invention six operation based on structuring
Make form list schematic diagram；
Figure 20 shows that conduit is to the right side in the according to embodiments of the present invention six report recording method of the operation based on structuring
Hat opening is treated and puts the operation record interface schematic diagram of support；
Figure 21 shows that conduit is to a left side in the according to embodiments of the present invention six report recording method of the operation based on structuring
Trunk opening is treated and puts the operation record interface schematic diagram of support；
Figure 22 shows that add module in recording method is reported according to embodiments of the present invention six operation based on structuring
Schematic diagram in operation record interface；
Figure 23 shows to add in the according to embodiments of the present invention six report recording method of the operation based on structuring and is sent into
Operation record interface schematic diagram after sacculus operation format；
Figure 24, which is shown in the according to embodiments of the present invention six report recording method of the operation based on structuring, inserts module
Schematic diagram in operation record interface；
Figure 25, which is shown in the according to embodiments of the present invention six report recording method of the operation based on structuring, is being sent into branch
The operation record interface schematic diagram inserted before frame operation format after being sent into sacculus operation format；
Figure 26, which is shown in the according to embodiments of the present invention six report recording method of the operation based on structuring, deletes unit
Schematic diagram in operation record interface.
Embodiment
Below with reference to the accompanying drawings and in conjunction with the embodiments, the present invention is described in detail.
Embodiment one
Fig. 1 shows the structural representation of the according to embodiments of the present invention one operation report record system based on structuring
Figure；As shown in figure 1, the system includes：Logging modle 10, selecting module 20, order module 30 and display module 40, wherein,
Logging modle 10, it is connected with selecting module 20, including N number of operation format, for according to the normal of each operation format
Rule require, the parameters of the operation format are configured in the form of structuring, and will be carried out with each operation format postponed
Individually storage；
Wherein, operation format can be that conduit reaches, puts seal wire, be sent into sacculus, be sent into support, medication etc., Mei Gecao
Making form has the custom requirements of its own, such as, as shown in Fig. 2 Fig. 2 show according to embodiments of the present invention one based on knot
The operation format list schematic diagram that conduit reaches in the operation report record system of structure, conduit reach this operation format, institute
The parameter being related to is the model of guiding catheter, and the lesions position that the conduit is reached is all settable on operation record interface
Form into drop-down menu clicks for doctor, to realize the operation of structuring；
For another example, as shown in figure 3, Fig. 3 shows the according to embodiments of the present invention one report record of the operation based on structuring
The operation format list schematic diagram of sacculus, this operation format of feeding sacculus are sent into system, how involved parameter is
Sacculus is sent into lesion, the model for having seal wire, the model of sacculus, expanded with how many ATM pressure, expansion the duration be
How much, after what degree etc. be expanded to, the form that can also be arranged to drop-down menu on operation record interface clicks for doctor；
And for example, as shown in figure 4, Fig. 4 shows the according to embodiments of the present invention one report record of the operation based on structuring
The operation format list schematic diagram of medication in system, this operation format of medication, involved parameter are route of administration, medication
Title and dosage and unit etc., the form that can be arranged to drop-down menu on operation record interface click for doctor.
Selecting module 20, it is connected respectively with logging modle 10 and order module 30, for the hand for needing to record based on doctor
The normal attribute of art, select operation format corresponding with the operation；
For example, to the record of radiography stent procedure, doctor carries out multiple vascular test, it is sometimes desirable to which repeatedly insertion conduit enters
Row checks, has corresponding to the routine operation form of radiography stent procedure：Conduit reach, put seal wire, be sent into sacculus, be sent into support,
Medication.
Order module 30, it is connected respectively with selecting module 20 and display module 40, for the routine operation according to the operation
Flow, the operation format after selection is ranked up, and its order is included on operation record interface；
For example, according to the routine operation flow of radiography stent procedure, the operation format corresponding to radiography stent procedure is entered
Row sequence, is ordered as：Conduit reaches, and plugs in conduit for the first time and enters a certain artery, again insertable into the artery if unsuccessful, 2 times
After unsuccessful, then another artery insertion is changed, if after inserting successfully, into seal wire operation format is put, seal wire inserts successfully laggard
Enter to be sent into sacculus operation format, it is big to stenosis, balloon expandable is carried out, expansion effect is described, if effect is failed to understand
It is aobvious, then carry out balloon expandable again, it is rear enter be sent into support operation format, be put into the support of certain model and specification, view result,
Period may encounter the operation format of medication, and the record of medication comes the bottom at operation record interface.
Display module 40, be connected with order module 30, in doctor the operation shape for all corresponding to the operation names
After the completion of the structured parameter editor that formula is configured, the structured parameter after the completion of editor is handled, generates natural language
Report, and natural language report is shown to client automatically.
The present embodiment is illustrated with example below：
For example, as shown in figure 5, Fig. 5 shows the according to embodiments of the present invention one report record of the operation based on structuring
Conduit is treated to right hat opening and puts the operation record interface schematic diagram of support in system, when doctor is selected in the right hat treatment hand of increase
During art, the brief surgical procedure of the operation is shown in the general introduction at operation record interface, i.e.,：Conduit reaches, seal wire is put into-right hat
Shape artery distal section, puts sacculus, puts support, put sacculus；And in details, sequentially show corresponding to all normal of the operation
Operation format is advised, i.e.,：Conduit reaches, puts seal wire, be sent into sacculus, be sent into support, be sent into sacculus；
As shown in fig. 6, Fig. 6 is shown in the according to embodiments of the present invention one report record system of the operation based on structuring
Conduit is treated to Left main artery opening and puts the operation record interface schematic diagram of support, and interface constituted mode is identical with Fig. 5, herein not
Repeat again, the doctor according to Fig. 5, Fig. 6 edits each operation format completed, and display module is to the structure after the completion of editor
Change parameter to be handled, generate natural language report, i.e., it is as follows：
" 1, arteria coronaria dextra therapeutic process：
6F JR4 guiding catheters are selected to reach right hat opening.(GW1) it is remote to be sent to arteria coronaria dextra for Runthrough seal wires
Section.Gusta NC 2.5*20mm sacculus is sent into lesion along (GW1) Runthrough, and check radiography has no that interlayer is formed, preceding
To 3 grades of blood flow TIMI.Stent1Firebird 3.0*18mm supports are sent into lesion, expansion is carried out with 18ATM pressure and released
Put.It is good to check radiography prompting stent expansion.Gusta NC3.5*15mm sacculus is sent into lesion along (GW1) Runthrough
Place, pressure expanded with 18-20ATM, check radiography has no that interlayer is formed, 3 grades of forward blood flow TIMI.Radiography is shown in that support is adherent good
It is good, have no Detecting Residual Stenosis and interlayer, forward blood flow TIMI3 levels.
2nd, Left main artery therapeutic process：
6F JL3.5 guiding catheters are selected to reach left hat opening.(GW1) Runthrough seal wires are sent to Left main artery.Edge
(GW1) Runthrough is sent into Gusta NC 2.5*20mm sacculus to lesion, check radiography and has no that interlayer is formed, forward direction blood
Flow 3 grades of TIMI.Stent1Firebird 3.0*18mm supports are sent into lesion, expansion release is carried out with 18ATM pressure.It is multiple
It is good to look into radiography prompting stent expansion.Gusta NC3.5*15mm sacculus is sent into lesion along (GW1) Runthrough, with
18-20ATM is pressure expanded, and check radiography has no that interlayer is formed, 3 grades of forward blood flow TIMI.Radiography is shown in that support is adherent good, not
See Detecting Residual Stenosis and interlayer, forward blood flow TIMI3 levels.
Without discomfort in patient's art.Radial artery sheath is pulled out, wrapping is fixed, send and return ward.Pay attention to observing vital sign, observation art
Side limbs blood supply situation.”
Embodiments of the invention are provided with logging modle, selecting module and order module, each operation in logging modle
Parameters involved by form, are all configured in the form of structuring, and are individually stored, and need writer in doctor
During art record report, selecting module then automatically chooses all operation formats corresponding to the operation, and order module is by root
The operation format order after selection is included on operation record interface according to the routine operation flow of the operation, doctor can basis
Actual flow, each operation format individually being edited, doctor only need to click parameters in each operation format,
The efficiency that doctor writes operation record report is greatly improved, and operation interface is directly perceived；Meanwhile it is also provided with showing in system
Show module, the structured parameter of each operation format after can doctor be edited carries out the generation of natural language, forms nature
Speech reporting, significantly increase the readability of report.
Embodiment two
Fig. 7 shows the structural representation of the according to embodiments of the present invention two operation report record system based on structuring
Figure；As shown in fig. 7, the system also includes：Add module 50, it is connected with logging modle 10, for when doctor is according to each operation
Actual demand, select an operation format automatically to include the operation format at operation record interface most when being added
Lower section.
The present embodiment is illustrated with example below：
Fig. 8 shows that according to embodiments of the present invention two operation based on structuring reports that add module exists in record system
Schematic diagram in operation record interface, as shown in figure 8, enumerating all operation formats in add module, added for doctor
Add operation, for example, according to operation demand, it is necessary to add the operation format for being sent into sacculus again, then doctor, which clicks, is sent into sacculus
Operation format, and the operation format that will be fed into sacculus is shown in the bottom at operation record interface, as shown in figure 9, Fig. 9 is shown
The hand that addition is sent into after sacculus operation format in the according to embodiments of the present invention two operation report record system based on structuring
Art records interface schematic diagram.
Embodiments of the invention because the form of ownership in system is all to be configured and configure in a conventional mode, therefore due to
The particularity of some operation, doctor can add operation format at any time according to the needs of surgical procedure, and the addition mould in the system
Block solves this problem, when doctor is according to the actual demand of each operation, when one operation format of selection is added, addition
Module automatically by the operation format include operation record interface bottom, facilitate doctor to perform the operation record report editor with
Modification.
Embodiment three
Figure 10 shows the structural representation of the according to embodiments of the present invention three operation report record system based on structuring
Figure；As shown in Figure 10, the system also includes：Module 60 is inserted, is connected with logging modle 10, for when doctor is according to each operation
Actual demand, an operation format is selected when being inserted, automatically by the upper of the currently displayed operation format of the operation format
Side.
The present embodiment is illustrated with example below：
Figure 11, which is shown in the according to embodiments of the present invention three report record system of the operation based on structuring, inserts module
Schematic diagram in operation record interface, as shown in figure 11, insert in module and enumerate all operation formats, carried out for doctor
Insertion operation, for example, according to operation demand, it is necessary to before support operation format is sent into insertion feeding sacculus operation format,
Then doctor clicks the operation format for being sent into sacculus in the case where being sent into support operation format, and the operation format that will be fed into sacculus is shown in
It is sent into above support operation format, as shown in figure 12, Figure 12 shows according to embodiments of the present invention three hand based on structuring
Operation record interface in art report record system after being sent into insertion before support operation format and being sent into sacculus operation format shows
It is intended to.
Embodiments of the invention because the form of ownership in system is all to be configured and configure in a conventional mode, therefore due to
The particularity of some operation, doctor can insert another behaviour under some operation format at any time according to the needs of surgical procedure
Make form, the insertion module in system can then be automatically inserted into the operation shape selected by a doctor above the operation format
Formula, the operation of doctor is facilitated, so that the view effect at operation record interface is obvious.
Example IV
Figure 13 shows the structural representation of the according to embodiments of the present invention four operation report record system based on structuring
Figure；As shown in figure 13, logging modle 10 also includes deleting unit 102, the actual demand for doctor according to each operation, selection
When one operation format is deleted, the operation format is deleted on operation record interface automatically.
The present embodiment is illustrated with example below：
Figure 14, which is shown in the according to embodiments of the present invention four report record system of the operation based on structuring, deletes unit
Schematic diagram in operation record interface, as shown in figure 14, according to operation needs, sacculus operation need not be put into surgical procedure
Form, then doctor be put into sacculus operation format, click deletion, then the operation format will be deleted on operation record interface.
Embodiments of the invention are also provided with deleting unit, and doctor can be carried out the operation format according to operation needs
Delete, the system is more beneficial for the operation of the editor of doctor, more hommization.
Embodiment five
Figure 15 shows the structural representation of the according to embodiments of the present invention five operation report record system based on structuring
Figure, as shown in figure 15, the system also includes：Enquiry module 70, it is connected with display module 40, for the nature inputted according to doctor
Language inquiry data, the historical record needed for doctor is included in client.
Embodiments of the invention are also provided with enquiry module, the natural language querying data that can be inputted according to doctor, will
Historical record needed for doctor is shown in client, can reach accurate inquiry, facilitates access of doctor's later stage to operation record.
Embodiment six
Figure 16 shows the flow chart of the according to embodiments of the present invention six operation report recording method based on structuring, such as
Shown in Figure 16, this method comprises the following steps：
Step S601, logging modle includes N number of operation format, according to the custom requirements of each operation format, with structuring
Form configure the parameters of the operation format, and will individually be stored with each operation format postponed；
Wherein, operation format can be that conduit reaches, puts seal wire, be sent into sacculus, be sent into support, medication etc., Mei Gecao
Making form has the custom requirements of its own, such as, as shown in figure 17, Figure 17 show according to embodiments of the present invention six based on
The operation format list schematic diagram that conduit reaches in the operation report recording method of structuring, conduit reach this operation format,
Involved parameter is the model of guiding catheter, the lesions position that the conduit is reached, can all be set on operation record interface
The form for being set to drop-down menu clicks for doctor, to realize the operation of structuring；
For another example, as shown in figure 18, Figure 18 shows the according to embodiments of the present invention six report note of the operation based on structuring
The operation format list schematic diagram of sacculus is sent into recording method, this operation format of feeding sacculus, involved parameter is such as
Sacculus is sent into lesion by what, the model for having seal wire, the model of sacculus, is expanded with how many ATM pressure, expands the duration
Be it is how many, after what degree etc. be expanded to, the form that can also be arranged to drop-down menu on operation record interface supplies doctor's point
Choosing；
And for example, as shown in figure 19, Figure 19 shows the according to embodiments of the present invention six report note of the operation based on structuring
The operation format list schematic diagram of medication in recording method, this operation format of medication, involved parameter are route of administration, are used
Medicine title and dosage and unit etc., the form that can be arranged to drop-down menu on operation record interface supply doctor's point
Choosing.
Step S602, the normal attribute for the operation for needing to record based on doctor, selecting module selection are corresponding with the operation
Operation format；
For example, to the record of radiography stent procedure, doctor carries out multiple vascular test, it is sometimes desirable to which repeatedly insertion conduit enters
Row checks, has corresponding to the routine operation form of radiography stent procedure：Conduit reach, put seal wire, be sent into sacculus, be sent into support,
Medication.
Step S603, order module are ranked up to the operation format after selection according to the routine operation flow of the operation,
And its order is included on operation record interface；
For example, according to the routine operation flow of radiography stent procedure, the operation format corresponding to radiography stent procedure is entered
Row sequence, is ordered as：Conduit reaches, and plugs in conduit for the first time and enters a certain artery, again insertable into the artery if unsuccessful, 2 times
After unsuccessful, then another artery insertion is changed, if after inserting successfully, into seal wire operation format is put, seal wire inserts successfully laggard
Enter to be sent into sacculus operation format, it is big to stenosis, balloon expandable is carried out, expansion effect is described, if effect is failed to understand
It is aobvious, then carry out balloon expandable again, it is rear enter be sent into support operation format, be put into the support of certain model and specification, view result,
Period may encounter the operation format of medication, and the record of medication comes the bottom at operation record interface.
Step S604, completed in the structured parameter editor that doctor configures the operation format for all corresponding to the operation
Afterwards, display module is handled the structured parameter after the completion of editor, generates natural language report, and automatically by natural language
Report is shown to client.
The present embodiment is illustrated with example below：
For example, as shown in figure 20, Figure 20 shows the according to embodiments of the present invention six report note of the operation based on structuring
Conduit is treated to right hat opening and puts the operation record interface schematic diagram of support in recording method, when doctor is selected in the right hat treatment of increase
During operation, the brief surgical procedure of the operation is shown in the general introduction at operation record interface, i.e.,：Conduit reaches, seal wire is put into the-right side
Coronary artery distal section, puts sacculus, puts support, puts sacculus；And in details, sequentially show corresponding to all of the operation
Routine operation form, i.e.,：Conduit reaches, puts seal wire, be sent into sacculus, be sent into support, be sent into sacculus；
As shown in figure 21, Figure 21 shows the according to embodiments of the present invention six report recording method of the operation based on structuring
Middle conduit is treated to Left main artery opening and puts the operation record interface schematic diagram of support, and interface constituted mode is identical with Figure 20,
This is repeated no more, and the doctor according to Figure 20, Figure 21 edits each operation format completed, after the completion of display module is to editor
Structured parameter handled, generate natural language report, i.e., it is as follows：
" 1, arteria coronaria dextra therapeutic process：
6F JR4 guiding catheters are selected to reach right hat opening.(GW1) it is remote to be sent to arteria coronaria dextra for Runthrough seal wires
Section.Gusta NC 2.5*20mm sacculus is sent into lesion along (GW1) Runthrough, and check radiography has no that interlayer is formed, preceding
To 3 grades of blood flow TIMI.Stent1Firebird 3.0*18mm supports are sent into lesion, expansion is carried out with 18ATM pressure and released
Put.It is good to check radiography prompting stent expansion.Gusta NC3.5*15mm sacculus is sent into lesion along (GW1) Runthrough
Place, pressure expanded with 18-20ATM, check radiography has no that interlayer is formed, 3 grades of forward blood flow TIMI.Radiography is shown in that support is adherent good
It is good, have no Detecting Residual Stenosis and interlayer, forward blood flow TIMI3 levels.
2nd, Left main artery therapeutic process：
6F JL3.5 guiding catheters are selected to reach left hat opening.(GW1) Runthrough seal wires are sent to Left main artery.Edge
(GW1) Runthrough is sent into Gusta NC 2.5*20mm sacculus to lesion, check radiography and has no that interlayer is formed, forward direction blood
Flow 3 grades of TIMI.Stent1Firebird 3.0*18mm supports are sent into lesion, expansion release is carried out with 18ATM pressure.It is multiple
It is good to look into radiography prompting stent expansion.Gusta NC3.5*15mm sacculus is sent into lesion along (GW1) Runthrough, with
18-20ATM is pressure expanded, and check radiography has no that interlayer is formed, 3 grades of forward blood flow TIMI.Radiography is shown in that support is adherent good, not
See Detecting Residual Stenosis and interlayer, forward blood flow TIMI3 levels.
Without discomfort in patient's art.Radial artery sheath is pulled out, wrapping is fixed, send and return ward.Pay attention to observing vital sign, observation art
Side limbs blood supply situation.”
This method also includes：When doctor is according to the actual demand of each operation, when selecting the operation format to be added,
The operation format is included the bottom at operation record interface by add module automatically.
The present embodiment is illustrated with example below：
Figure 22 shows that add module in recording method is reported according to embodiments of the present invention six operation based on structuring
Schematic diagram in operation record interface, all operation formats are enumerated as shown in figure 22, in add module, carried out for doctor
Addition operation, for example, according to operation demand, it is necessary to add the operation format for being sent into sacculus again, then doctor clicks feeding sacculus
Operation format, and the operation format that will be fed into sacculus is shown in the bottom at operation record interface, and as shown in figure 23, Figure 23 shows
Go out in the according to embodiments of the present invention six report recording method of the operation based on structuring after addition feeding sacculus operation format
Operation record interface schematic diagram.
This method also includes：When doctor is according to the actual demand of each operation, when selecting the operation format to be inserted,
Module is inserted automatically by the top of the currently displayed operation format of the operation format.
The present embodiment is illustrated with example below：
Figure 24, which is shown in the according to embodiments of the present invention six report recording method of the operation based on structuring, inserts module
Schematic diagram in operation record interface, as shown in figure 24, insert in module and enumerate all operation formats, carried out for doctor
Insertion operation, for example, according to operation demand, it is necessary to before support operation format is sent into insertion feeding sacculus operation format,
Then doctor clicks the operation format for being sent into sacculus in the case where being sent into support operation format, and the operation format that will be fed into sacculus is shown in
It is sent into above support operation format, as shown in figure 25, Figure 25 shows according to embodiments of the present invention six hand based on structuring
Operation record interface in art report recording method after being sent into insertion before support operation format and being sent into sacculus operation format shows
It is intended to.
This method also includes：Doctor when one operation format of selection is deleted, remembers according to the actual demand of each operation
Deletion unit in record module automatically deletes the operation format on operation record interface.
The present embodiment is illustrated with example below：
Figure 26, which is shown in the according to embodiments of the present invention six report recording method of the operation based on structuring, deletes unit
Schematic diagram in operation record interface, as shown in figure 26, according to operation needs, sacculus operation need not be put into surgical procedure
Form, then doctor be put into sacculus operation format, click deletion, then the operation format will be deleted on operation record interface.
This method also includes：The natural language querying data that enquiry module inputs according to doctor, by the history needed for doctor
Record is shown in client.
In embodiments of the invention, the parameters involved by each operation format in logging modle, all with structure
The form of change is configured, and is individually stored, and when doctor needs writer's art record report, selecting module then automatically will be right
It should be chosen in all operation formats of the operation, order module is by the routine operation flow according to the operation by after selection
Operation format order is shown on operation record interface, and doctor can be carried out independent according to actual flow to each operation format
Editor, doctor only need to click parameters in each operation format, greatly improve doctor and write operation record report
The efficiency of announcement, and operation interface is directly perceived；Meanwhile display module doctor can be edited after each operation format structuring
Parameter carries out the generation of natural language, forms natural language report, significantly increases the readability of report；Due in system
Form of ownership is all to be configured and configure in a conventional mode, therefore because the particularity of some operation, doctor can be according to performing the operation
The needs of journey, operation format is added at any time, and the add module in this method solves this problem, when doctor is according to each hand
The actual demand of art, when one operation format of selection is added, the operation format is included remembering in operation by add module automatically
The bottom at interface is recorded, facilitates editor and modification of the doctor to record report of performing the operation；Due to the form of ownership in system be all with
Normal mode is configured and configured, therefore because the particularity of some operation, doctor can at any time can according to the needs of surgical procedure
Under some operation format, another operation format is inserted, the insertion module in method then can be in the top of the operation format
The operation format selected by a doctor is automatically inserted into, facilitates the operation of doctor, so that the visual angle at operation record interface
Positive effect；Because this method also includes delete step, doctor can be deleted the operation format according to operation needs,
This method is set to be more beneficial for the operation of the editor of doctor, more hommization；The present invention is also provided with enquiry module, can be according to doctor
The natural language querying data of raw input, the historical record needed for doctor is included, in client, accurate inquiry can be reached, side
Just access of doctor's later stage to operation record.
From the above description, it can be seen that the above embodiment of the present invention realizes following technique effect：The reality of the present invention
Apply in example, it is each involved by each operation format in logging modle there is provided logging modle, selecting module and order module
Individual parameter, is all configured in the form of structuring, and is individually stored, when doctor needs writer's art record report, choosing
Select module then automatically to choose all operation formats corresponding to the operation, order module will be grasped according to the routine of the operation
Making flow includes the operation format order after selection on operation record interface, and doctor can be according to actual flow, to each
Operation format is individually edited, and doctor only need to click parameters in each operation format, greatly improve doctor
The raw efficiency for writing operation record report, and operation interface is directly perceived；Meanwhile display module is also provided with system, it can incite somebody to action
Doctor edit after each operation format structured parameter carry out natural language generation, formed natural language report, greatly
The readability for adding report；Because the form of ownership in system is all to be configured and configure in a conventional mode, therefore due to
The particularity of some operation, doctor can add operation format at any time according to the needs of surgical procedure, and the addition mould in the system
Block solves this problem, when doctor is according to the actual demand of each operation, when one operation format of selection is added, addition
Module automatically by the operation format include operation record interface bottom, facilitate doctor to perform the operation record report editor with
Modification；Because the form of ownership in system is all to be configured and configure in a conventional mode, thus due to some operation particularity,
Doctor can insert another operation format, inserting in system according to the needs of surgical procedure under some operation format at any time
Operation format selected by a doctor can be then automatically inserted into above the operation format by entering module, facilitate the behaviour of doctor
Make, so that the view effect at operation record interface is obvious；Due to being also provided with deleting unit, doctor can be according to operation need
Will, the operation format is deleted, the system is more beneficial for the operation of the editor of doctor, more hommization；Due to also setting
Enquiry module has been put, the natural language querying data that can be inputted according to doctor, the historical record needed for doctor has been included in visitor
Family end, accurate inquiry can be reached, facilitate access of doctor's later stage to operation record.
Obviously, those skilled in the art should be understood that above-mentioned each module of the invention or each step can be with general
Computing device realize that they can be concentrated on single computing device, or be distributed in multiple computing devices and formed
Network on, alternatively, they can be realized with the program code that computing device can perform, it is thus possible to they are stored
Performed in the storage device by computing device, either they are fabricated to respectively each integrated circuit modules or by they
In multiple modules or step be fabricated to single integrated circuit module to realize.So, the present invention is not restricted to any specific
Hardware and software combines.
The preferred embodiments of the present invention are the foregoing is only, are not intended to limit the invention, for the skill of this area
For art personnel, the present invention can have various modifications and variations.Within the spirit and principles of the invention, that is made any repaiies
Change, equivalent substitution, improvement etc., should be included in the scope of the protection.
Claims (10)
1. a kind of operation report record system based on structuring, it is characterised in that including logging modle, selecting module, sequence
Module and display module, wherein,
The logging modle, it is connected with the selecting module, including N number of operation format, for according to each operation format
Custom requirements, the parameters of the operation format are configured in the form of structuring, and by with each operation postponed
Form is individually stored；
The selecting module, it is connected respectively with the logging modle and the order module, for needing what is recorded based on doctor
The normal attribute of operation, select operation format corresponding with the operation；
The order module, it is connected respectively with the selecting module and the display module, is grasped for the routine according to the operation
Make flow, the operation format after selection is ranked up, and its order is included on operation record interface；
The display module, be connected with the order module, in doctor the operation format institute for all corresponding to the operation
After the completion of the structured parameter editor of configuration, the structured parameter after the completion of editor is handled, generates natural language report,
And the natural language report is shown to client automatically.
2. the operation report record system according to claim 1 based on structuring, it is characterised in that the system is also wrapped
Include：Add module, it is connected with the logging modle, for when doctor is according to the actual demand of each operation, selecting described in one
When operation format is added, the operation format is included into the bottom at the operation record interface automatically.
3. the operation report record system according to claim 1 based on structuring, it is characterised in that the system is also wrapped
Include：Module is inserted, is connected with the logging modle, for when doctor is according to the actual demand of each operation, selecting described in one
When operation format is inserted, automatically by the top of the currently displayed operation format of the operation format.
4. the operation report record system according to claim 1 based on structuring, it is characterised in that the logging modle
Also including deletion unit, the actual demand for doctor according to each operation, when one operation format of selection is deleted,
Automatically the operation format is deleted on the operation record interface.
5. the operation report record system according to claim 1 based on structuring, it is characterised in that the system is also wrapped
Include：Enquiry module, it is connected with the display module, for the natural language querying data inputted according to doctor, by needed for doctor
Historical record be shown in client.
A kind of 6. operation report recording method based on structuring, it is characterised in that including：
Logging modle includes N number of operation format, according to the custom requirements of each operation format, is matched somebody with somebody in the form of structuring
The parameters of the operation format are put, and will individually be stored with each operation format postponed；
The normal attribute for the operation for needing to record based on doctor, selecting module select operation format corresponding with the operation；
Order module is ranked up, and its order is shown according to the routine operation flow of the operation to the operation format after selection
Show on operation record interface；
After the completion of the structured parameter editor that doctor configures the operation format for all corresponding to the operation, display module pair
Structured parameter after the completion of editor is handled, and generates natural language report, and automatically show the natural language report
To client.
7. the operation report recording method according to claim 6 based on structuring, it is characterised in that this method is also wrapped
Include：When doctor is according to the actual demand of each operation, when one operation format of selection is added, add module automatically will
The operation format is shown in the bottom at the operation record interface.
8. the operation report recording method according to claim 6 based on structuring, it is characterised in that this method is also wrapped
Include：When doctor is according to the actual demand of each operation, when one operation format of selection is inserted, insertion module automatically will
The top of the currently displayed operation format of the operation format.
9. the operation report recording method according to claim 6 based on structuring, it is characterised in that this method is also wrapped
Include：Doctor is according to the actual demand of each operation, when selecting the operation format to be deleted, the deletion in logging modle
Unit automatically deletes the operation format on the operation record interface.
10. the operation report recording method according to claim 6 based on structuring, it is characterised in that this method is also wrapped
Include：The natural language querying data that enquiry module inputs according to doctor, the historical record needed for doctor is included in client.
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| CN201710570938.0A CN107526919A (en) | 2017-07-13 | 2017-07-13 | Operation report record system and its recording method based on structuring |
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| Publication number | Priority date | Publication date | Assignee | Title |
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| CN112597107A (en) * | 2020-11-30 | 2021-04-02 | 煤炭科学技术研究院有限公司 | Inspection report generation method, device, electronic equipment and storage medium |
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| CN103559674A (en) * | 2013-11-25 | 2014-02-05 | 方正国际软件有限公司 | Structured entry device and method of medical record document |
| CN106845139A (en) * | 2017-02-28 | 2017-06-13 | 北京赛迈特锐医疗科技有限公司 | Structured report is generated the system and method for natural language report |
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| US20130191154A1 (en) * | 2012-01-22 | 2013-07-25 | Dobkin William R. | Medical data system generating automated surgical reports |
| CN103559674A (en) * | 2013-11-25 | 2014-02-05 | 方正国际软件有限公司 | Structured entry device and method of medical record document |
| CN106845139A (en) * | 2017-02-28 | 2017-06-13 | 北京赛迈特锐医疗科技有限公司 | Structured report is generated the system and method for natural language report |
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| Publication number | Priority date | Publication date | Assignee | Title |
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| CN108665951A (en) * | 2018-04-16 | 2018-10-16 | 北京天使软件技术有限公司 | A kind of method and system that pre- structural data is generated to medical report |
| CN108665951B (en) * | 2018-04-16 | 2022-01-28 | 北京天使软件技术有限公司 | Method and system for generating medical report from pre-structured data |
| CN112597107A (en) * | 2020-11-30 | 2021-04-02 | 煤炭科学技术研究院有限公司 | Inspection report generation method, device, electronic equipment and storage medium |
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Application publication date: 20171229 |