CN108122601A - A kind of emergency treatment _ based Patient Records Management Systems and management method - Google Patents
A kind of emergency treatment _ based Patient Records Management Systems and management method Download PDFInfo
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- CN108122601A CN108122601A CN201711431091.4A CN201711431091A CN108122601A CN 108122601 A CN108122601 A CN 108122601A CN 201711431091 A CN201711431091 A CN 201711431091A CN 108122601 A CN108122601 A CN 108122601A
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Abstract
The embodiment of the invention discloses a kind of emergency treatment _ based Patient Records Management Systems and management method, wherein, which includes：Emergency treatment electronic medical record system, emergency treatment interface service module, information management system and emergency treatment sign acquisition module；Emergency treatment electronic medical record system, for obtaining the sign data of patient from emergency treatment sign acquisition module, and obtain the inspection application information of patient and inspection request information from information management system, and from medical image information system and clinical laboratory's information system obtain respectively patient inspection result information and inspection result information and based on sign data, check application information, inspection request information, inspection result information and inspection result information generation electronic health record.The embodiment of the present invention can conveniently check the complete information of patient, optimize the treatment flow of emergency treatment, improve emergency treatment work efficiency and quality.
Description
Technical field
The present invention relates to medical information processing technology field more particularly to a kind of emergency treatment _ based Patient Records Management Systems and management
Method.
Background technology
Electronic medical record system is had been widely used in most of hospitals at present, is broadly divided into patient medical history system with being hospitalized
Two big classification of medical records system.Wherein, patient medical history system can be divided into two kinds of general out patient service medical records system, emergency record system.But
The particularity due to emergency department so that it have the characteristics that with other each sections of hospital it is dramatically different, for example, emergency department patient stream
Rotary speed is fast, and the state of an illness is complicated and changeable, and acatalepsia is true etc..This requires the medical staff of emergency department improves the same of work efficiency
When, also to ensure work quality, quickly, accurately and efficiently to carrying out diagnosis and treatment to examine patient.Therefore, it is quick to be formed comprising patient
The electronic health record of each side complete information is particularly significant to the effectively treatment of Emergency Patients.
It is independent between existing emergency treatment electronic medical record system and hospital's other systems, therefore, some of patient are sick
Going through information can not directly acquire, it is impossible to comparatively fast form complete electronic health record, affect the efficiency of emergency treatment.
The content of the invention
The embodiment of the present invention provides a kind of emergency treatment _ based Patient Records Management Systems and management method, easy to operate, conveniently checks
The complete information of patient optimizes the treatment flow of emergency treatment, can improve emergency treatment work efficiency and quality.
In a first aspect, an embodiment of the present invention provides a kind of emergency treatment _ based Patient Records Management Systems, including：Emergency treatment electronic health record
System, emergency treatment interface service module, information management system and emergency treatment sign acquisition module；
The emergency treatment sign acquisition module is connected with external monitor, for gathering patient from the monitor
Sign data；
Described information management system is connected by the emergency treatment interface service module with the emergency treatment electronic medical record system, is used
It is operated according to the application of emergency physicians, generates the inspection application information of the patient and inspection request information；
The emergency treatment electronic medical record system is connected by the emergency treatment interface service module and the emergency treatment sign acquisition module
It connects, and is connected by clinical laboratory information system of the emergency treatment interface service module respectively with external Medical Imaging System and outside
It connects, for obtaining the sign data of the patient from the emergency treatment sign acquisition module, and is obtained from described information management system
The inspection application information and inspection request information of the patient and believe from the medical image information system and the clinical laboratory
Breath system obtains the inspection result information of the patient and inspection result information and based on the sign data, described respectively
Check application information, the inspection request information, the inspection result information and inspection result information generation electronic health record.
Second aspect, the embodiment of the present invention additionally provide a kind of emergency treatment electronic health record management method, including：
Emergency treatment electronic medical record system obtains the sign of patient by emergency treatment interface service module from emergency treatment sign acquisition module
Data；
The emergency treatment electronic medical record system obtains the trouble by the emergency treatment interface service module from information management system
The inspection application information of person and inspection request information；
The emergency treatment electronic medical record system obtains institute by the emergency treatment interface service module from medical image information system
It states the inspection result information of patient and the inspection result information of the patient is obtained from clinical laboratory's information system；
The emergency treatment electronic medical record system is based on the sign data, the inspection application information, inspection request letter
Breath, the inspection result information and inspection result information generation electronic health record.
Technical solution provided in an embodiment of the present invention, by the way that emergency treatment electronic medical record system is gathered mould with emergency treatment sign respectively
Block, information management system, the medical image information system of outside and the information management system connection of the clinical laboratory of outside, so that anxious
Examining electronic medical record system can communicate with other systems, and the information of patient is corresponded to from each system, form electronic health record,
It avoids each system in the prior art and isolates the problem of being inconvenient to check patient medical record information, the treatment stream of emergency treatment can be optimized
Journey improves emergency treatment work efficiency and quality；Patient or patient with severe symptoms especially for breakthrough symptoms etc. can make emergency treatment
Doctor facilitates the medical record information for obtaining patient, to strive for faster treating for patient.
Description of the drawings
By reading the detailed description made to non-limiting example made with reference to the following drawings, of the invention is other
Feature, objects and advantages will become more apparent upon：
Fig. 1 is a kind of emergency treatment _ based Patient Records Management Systems structure diagram provided by one embodiment of the present invention；
Fig. 2 is a kind of emergency treatment _ based Patient Records Management Systems structure diagram provided by one embodiment of the present invention；
Fig. 3 is a kind of emergency treatment electronic health record management method flow chart provided by one embodiment of the present invention；
Fig. 4 is a kind of emergency treatment electronic health record management method flow chart provided by one embodiment of the present invention.
Specific embodiment
The present invention is described in further detail with reference to the accompanying drawings and examples.It is understood that this place is retouched
The specific embodiment stated is used only for explaining the present invention rather than limitation of the invention.It also should be noted that in order to just
Part related to the present invention rather than full content are illustrated only in description, attached drawing.
Fig. 1 is a kind of structure diagram of emergency treatment _ based Patient Records Management Systems provided by one embodiment of the present invention, described
Emergency treatment _ based Patient Records Management Systems are applied to management of the emergency treatment section office of hospital to electronic health record.Wherein, emergency treatment electronic health record pipe
Reason system is realized by software and/or hardware, as shown in Figure 1, emergency treatment _ based Patient Records Management Systems include：Emergency treatment electronic health record system
System 11, emergency treatment interface service module 12, information management system 13 and emergency treatment sign acquisition module 14.
Wherein, emergency treatment sign acquisition module 14 is connected with external monitor, for gathering patient from monitor
Sign data.Wherein, the sign data of patient can be cardiac monitoring data etc..Emergency treatment sign acquisition module 14 is from patient monitor
Can obtain in real time when sign data is obtained in device, preset time can also be spaced and obtained.
In embodiments of the present invention, information management system 13 (Hospital Information System, HIS) passes through
Emergency treatment interface service module 12 is connected with emergency treatment electronic medical record system 11, and for being operated according to the application of emergency physicians, generation is suffered from
The inspection application information of person and inspection request information.
Wherein, the conventional masterplate of information management system 13 include outpatient service management, hospital management, pharmacy management, Drugstore management,
President's inquiry, electronic prescription, handling of goods and materials, media management etc. provide more sound assurance for hospital management.Information management system
13 systems are served as theme with financial information, patient information and material information, by the collection of information, storage, transmission, statistics, point
Analysis, comprehensive inquiry, report output and information sharing can provide comprehensively and accurately various numbers for all departments staff in time
According to.
Wherein, when emergency treatment log-on message manages system 13, emergency physicians can be in information management system 13 according to trouble
Symptom of person etc. applies for inspection, inspection etc. for patient.When emergency physicians carry out inspection application, inspection in information management system 13
During application operation, information management system 13 receives the application operation of emergency physicians, generates inspection application information and the inspection of patient
Test application information.Wherein, check that application information can include the inspection application information of the images classes such as color ultrasound, rabat, inspection request
Information can include the inspection requests information such as routine urinalysis, blood.
As shown in Figure 1, emergency treatment electronic medical record system 11 passes through emergency treatment interface service module 12 and emergency treatment sign acquisition module
14 connections, and pass through emergency treatment interface service module 12 respectively with external medical image system 15 and external clinical laboratory's information system
16 connections for obtaining the sign data of patient from emergency treatment sign acquisition module 14, and obtain patient from information management system 13
Inspection application information and inspection request information and obtained respectively from medical image information system 15 and clinical laboratory's information system 16
Take patient inspection result information and inspection result information and based on sign data, check application information, inspection request letter
Breath, inspection result information and inspection result information generation electronic health record.
Wherein, emergency treatment interface service module 12, it is possible to understand that be between emergency treatment electronic medical record system 11 and other systems into
The interface of row communication.
In embodiments of the present invention, (the Picture Archiving and of medical image information system 15
Communication Systems, PACS) it is connected by emergency treatment interface service module 12 with emergency treatment electronic medical record system 11, it uses
In the inspection result information of storage patient；Clinical laboratory's information system 16 (Laboratory Information System, LIS)
It is connected by emergency treatment interface service module 12 with emergency treatment electronic medical record system 11, for storing the inspection result information of patient.Its
In, inspection result information can include the check image of patient and the diagnostic message of patient that is determined based on image or also
It can include suggestion provided for patient etc..Wherein, inspection result information can include the inspection data of patient, based on data
Definite diagnostic message, to suggestion of patient etc..
Wherein, as shown in Figure 1, emergency treatment electronic medical record system 11 obtains the inspection knot of patient from medical image information system 15
Fruit information can be following flow：Emergency treatment electronic medical record system 11 checks patient's inspection to the transmission of medical image information system 15
The request of result information, medical image information system 15 suffer from this according to the inspection result information of the requesting query patient
The inspection result information of person is sent to emergency treatment electronic medical record system 11, and emergency treatment electronic medical record system 11 receives the inspection knot of the patient
Fruit information.Wherein, emergency treatment electronic medical record system 11 from clinical laboratory's information system 16 obtain patient inspection result method with from
The Method And Principle that medical image information system 15 obtains the inspection result information of patient is identical, is not repeated.
Optionally, electronic health record can have different templates, for example, can include commonly examining a version, rescue version, stay
Version is seen, emergency physicians can give treatment to the template of regional choice patient electronic medical record according to patient, be conducive to emergency treatment requirements of one's work,
Improve the efficiency of emergency treatment work.Optionally, electronic health record can be divided into different columns, and each column records the disease of corresponding patient
Go through information.For example, it may be patient basis's column, sign data record column, inspection result column, inspection result column
Deng.Electronic health record is divided into different columns as a result, doctor can be facilitated to browse the information of patient.
It can be following process to form electronic health record by above-mentioned each system：
When emergency physicians input the sign data of patient in emergency treatment electronic medical record system 11, emergency treatment electronic medical record system
11 can gather the sign data of patient by emergency treatment sign acquisition module 14 from monitor.When emergency physicians are in emergency treatment electricity
After sub- medical records system 11 inputs the diagnostic message of patient, information management system 13 can be started, inputted in information management system 13
The inspection application information of patient and inspection request information.By information management system 13 generate patient inspection application information and
Inspection request information, emergency treatment electronic medical record system 11 can obtain the inspection application of the patient of the generation of information management system 13 automatically
Information and inspection request information.When inspection result of the emergency physicians in the input patient of emergency treatment electronic medical record system 11 and inspection
When as a result, can respectively it be obtained from medical image information system 15 and clinical laboratory's information system 16 by emergency treatment interface service module 12
The inspection result information and inspection result information taken.
Emergency treatment electronic medical record system believes the sign data of the patient of acquisition, inspection application information, inspection request as a result,
Breath, inspection result information and inspection result information etc. generate the electronic health record of patient according to setting module.Or can also be anxious
It examines after doctor sets electronic health record template according to patient's actual conditions, emergency treatment electronic medical record system is by the sign number of the patient of acquisition
According to, check that application information, inspection request information, inspection result information and inspection result information etc. are added to the electronic health record of setting
In template, to generate electronic health record.
Technical solution provided in an embodiment of the present invention, by the way that emergency treatment electronic medical record system is gathered mould with emergency treatment sign respectively
Block, information management system, the medical image information system of outside and the information management system connection of the clinical laboratory of outside, so that anxious
Examining electronic medical record system can communicate with other systems, and the information of patient is corresponded to from each system, form electronic health record,
It avoids each system in the prior art and isolates the problem of being inconvenient to check patient medical record information, the treatment stream of emergency treatment can be optimized
Journey improves emergency treatment work efficiency and quality；Patient or patient with severe symptoms especially for breakthrough symptoms etc. can make emergency treatment
Doctor facilitates the medical record information for obtaining patient, to strive for faster treating for patient.
Optionally, in one embodiment of the embodiment of the present invention, as shown in Figure 1, information management system 13, is additionally operable to obtain
Prescription information of the emergency physicians based on the information input in electronic health record；Wherein, the information in electronic health record include sign data,
At least one of in inspection result information and inspection result information；Emergency treatment electronic medical record system 11 is additionally operable to from information management system
Prescription information is obtained in system 13, and prescription information is added in electronic health record.
Wherein, when emergency physicians are in the browsing electronic health record of emergency treatment electronic medical record system 11, emergency treatment electronic health record system is clicked on
The setting position united in 11 display interfaces can be jumped to information management system 13, emergency treatment doctor by emergency treatment electronic medical record system 11
It is raw that prescription information can be inputted in information management system 13 based on the information in electronic health record.When emergency physicians are in emergency treatment electronics disease
Go through system 11 carry out input prescription information operation when, emergency treatment electronic medical record system 11 from information management system 13 obtain prescription letter
Breath, and prescription information is added in electronic health record.
Prescription information is obtained from information management system by emergency treatment electronic medical record system automatically as a result, and prescription is believed
Breath is added in electronic health record, can quickly improve the electronic health record of emergency treatment, improves emergency treatment work efficiency, and can facilitate urgency
It examines doctor and consults emergency treatment electronic health record, avoid the work of a large amount of Hand writings, ensure the accuracy of electronic health record.
As shown in Figure 1, in one embodiment of the embodiment of the present invention, information management system 13 is additionally operable to obtain electronics
Information in case history, and based on the corresponding prescription information of information recommendation in electronic health record；Information in electronic health record includes body
Levy at least one in data, inspection result information and inspection result information；Emergency treatment electronic medical record system 11 is additionally operable to from information
Prescription information is obtained in management system 13, and prescription information is added in electronic health record.
Wherein, when emergency physicians information management system 13 carry out input prescription information operation when, information management system
13 can obtain the information in electronic health record, based on the corresponding prescription information of information recommendation in electronic health record.Specifically, can be with
The correspondence between sign data, inspection result information, inspection result information and prescription information is established, according in electronic information
The corresponding prescription information of information matches, and matched prescription information is supplied to emergency physicians, so that emergency physicians refer to.Its
In, method of the information management system 13 based on the corresponding prescription information of information recommendation in electronic health record can also be its other party
Formula.
It can be improved based on the corresponding prescription information of information recommendation in electronic health record by information management system as a result,
The efficiency of prescription under emergency physicians obtains prescription information from information management system automatically by emergency treatment electronic medical record system, and will
Prescription information is added in electronic health record, and emergency physicians can be facilitated to consult emergency treatment electronic health record, avoid a large amount of Hand writings
Work, improve emergency treatment work efficiency, and ensure the accuracy of electronic health record.
In the embodiment of one embodiment of the invention, as shown in Fig. 2, optionally, emergency treatment _ based Patient Records Management Systems
It can also include emergency treatment helper module 17.
Wherein, emergency treatment helper module 17 can be an auxiliary program.It in embodiments of the present invention, as shown in Fig. 2, can
Choosing, emergency treatment electronic medical record system 11 is additionally operable to send to information management system 13 by emergency treatment interface service module 12 and hold a consultation
Application information, wherein, the information of carrying patient in application information of holding a consultation.Information management system 13 connects with emergency treatment helper module 17
It connects, is additionally operable to when receiving the operation of consultant's opening consultation of doctors application information, by calling emergency treatment helper module 17 to urgency
It examines electronic medical record system 11 and sends the request for checking patient electronic medical record, and receive the patient of the transmission of emergency treatment electronic medical record system 11
Electronic health record and the electronic health record of patient is shown to be supplied to consultant.
Optionally, as shown in Fig. 2, emergency treatment _ based Patient Records Management Systems provided in an embodiment of the present invention can also include nursing
System 18, wherein, nursing system 18, for storing the nursing information of patient.Wherein, nursing doctor can be in nursing system 18
The nursing information of patient is write, nursing system 18 simultaneously stores the nursing information of patient.Optionally, information management system
13, it is additionally operable to when the operation for receiving consultant's opening consultation of doctors application information, by calling emergency treatment helper module 17 to nursing
System 18 sends the request for checking patient care, and receives the nursing information of the patient of the transmission of emergency treatment electronic medical record system 11, with
And the nursing information of patient is shown to be supplied to consultant.Information management system 13, is additionally operable to by calling emergency treatment
Helper module 17 obtains the consultation of doctors opinion of electronic health record and/or nursing information input of the consultant based on patient.Optionally, it is anxious
Electronic medical record system 11 is examined, is additionally operable to obtain consultation of doctors opinion from emergency treatment helper module 17, and consultation of doctors opinion is added to electronics disease
In going through.
Specifically, when the patient sign of emergency department is unstable or during treatment complexity, it is necessary to which multiple doctors are into guild
It examines.Emergency physicians are operated in emergency treatment electronic medical record system 11, pass through emergency treatment interface service by emergency treatment electronic medical record system 11
Module 12 sends consultation of doctors application information to information management system 13, wherein, the information of carrying patient, example in application information of holding a consultation
Such as, number, name etc..When consultant is in log-on message management system 13 on the terminal device of place section office, can check
To consultation of doctors solicitation message.When consultant opens consultation of doctors solicitation message, information management system 13 receives consultant's opening
The operation for solicitation message of holding a consultation is called emergency treatment helper module 17, is sent out from emergency treatment helper module 17 to emergency treatment electronic medical record system 11
The request for checking patient electronic medical record is sent, and receives the electronic health record of the patient of the transmission of emergency treatment electronic medical record system 11 and incites somebody to action
The electronic health record of patient is shown to be supplied to consultant.Consultant can help according to the information of electronic health record in emergency treatment
Input consultation of doctors opinion, emergency treatment helper module 17 obtain the consultation of doctors opinion of consultant's input in fingerprint block 17.
Optionally, when consultant opens consultation of doctors solicitation message, information management system 13 receives consultant's opening
Emergency treatment helper module 17 is called in the operation for solicitation message of holding a consultation, and can also be sent to nursing system 18 and be checked care
Request, and receive nursing system 18 transmission patient nursing information and the nursing information of patient is shown to carry
Consultant is supplied, consultant can also input consultation of doctors opinion according to the nursing information and electronic health record of patient.Work as emergency treatment
When doctor checks the consultation of doctors opinion of patient in emergency treatment electronic medical record system 11, emergency treatment electronic medical record system 11, which receives, checks trouble
The operation of person's consultation of doctors opinion obtains the consultation of doctors opinion of patient from emergency treatment helper module 17, and consultation of doctors opinion is added to patient's
In electronic health record.
As a result, by using emergency treatment helper module, and emergency treatment electronic medical record system, information management system etc. are attached
To communicate, can be held a consultation opinion with quick obtaining, striven for more times for patient's treatment, and improved work efficiency.
It should be noted that when consultant opens consultation of doctors solicitation message, information management system receives consultant
The operation of consultation of doctors solicitation message is opened, calls emergency treatment helper module can be simultaneously to emergency treatment electronic medical record system and nursing system point
It Fa Song not check request, can not also be sent respectively to emergency treatment electronic medical record system and nursing system simultaneously and check request, also may be used
Only to check request to emergency treatment electronic medical record system transmission.
It should be noted that when in the rescue room in emergency treatment, consultant can not on the terminal device of rescue room
Log-on message manages system, can directly open emergency treatment helper module, is inputted consultation of doctors opinion by emergency treatment helper module,
So that emergency treatment electronic medical record system will hold a consultation, opinion is added in electronic medical record system.The time can be saved, improves work efficiency.
Wherein, in embodiments of the present invention, emergency treatment electronic medical record system can also be connected with printer, realize electronic health record
Automatic printing or the printing according to emergency physicians, realize the printing of electronic health record.And emergency treatment electronic medical record system
Electronic health record can also be converted into PDF format, so that other doctors are had access to.
In embodiments of the present invention, by emergency treatment electronic medical record system and information management system, medical image information system,
Clinical laboratory's information system, sign acquisition module etc. communicate, and can obtain complete electronic health record automatically, can be to disease
It counts the statistical analysis of evidence one by one, is conducive to hospital and summarizes the spectrum of disease of each period, the onset peak of disease, summary treatment warp
It tests, optimize emergency treatment flow etc..
Fig. 3 is a kind of flow chart of emergency treatment electronic health record management method provided by one embodiment of the present invention, the method
It is performed by emergency treatment _ based Patient Records Management Systems provided in an embodiment of the present invention, as shown in figure 3, skill provided in an embodiment of the present invention
Art scheme includes：
S310：Emergency treatment electronic medical record system obtains patient's by emergency treatment interface service module from emergency treatment sign acquisition module
Sign data.
In embodiments of the present invention, emergency treatment interface takes module, it can be understood as emergency treatment electronic medical record system and other systems
Between the interface that communicates.Wherein, emergency treatment sign acquisition module is connected with external monitor, can be from monitor
Gather the sign data of patient.
S320：The emergency treatment electronic medical record system obtains institute by the emergency treatment interface service module from information management system
State the inspection application information of patient and inspection request information.
In embodiments of the present invention, emergency physicians can input inspection application information and the inspection of patient in information management system
Application information is tested, information management system can obtain the inspection application information of patient and inspection request information.
S330：The emergency treatment electronic medical record system is obtained by the emergency treatment interface service module from medical image information system
It takes the inspection result information of the patient and the inspection result information of the patient is obtained from clinical laboratory's information system.
In embodiments of the present invention, medical image information system, for storing the inspection result information of patient.Clinical laboratory believes
Breath system, for storing the inspection result information of patient.
S340：The emergency treatment electronic medical record system is based on the sign data, the inspection application information, the inspection Shen
It please information, the inspection result information and inspection result information generation electronic health record.
In embodiments of the present invention, emergency treatment electronic medical record system can apply for the sign data of the patient of acquisition, inspection
Information, inspection request information, inspection result information and inspection result information etc. generate the electronic health record of patient according to setting module.
Or can also be after emergency physicians set electronic health record template according to patient's actual conditions, emergency treatment electronic medical record system will obtain
Patient sign data, check that application information, inspection request information, inspection result information and inspection result information etc. are added to
In the electronic health record template of setting, to generate electronic health record.
Technical solution provided in an embodiment of the present invention, by the way that emergency treatment electronic medical record system is gathered mould with emergency treatment sign respectively
Block, information management system, medical image information system and clinical laboratory's information management system connection, so that emergency treatment electronic health record system
System can communicate with other systems, and the information of patient is corresponded to from each system, form electronic health record, avoid existing skill
Each system isolates the problem of being inconvenient to check patient medical record information in art, can optimize the treatment flow of emergency treatment, improves emergency treatment
Work efficiency and quality；Patient or patient with severe symptoms especially for breakthrough symptoms etc. can be such that emergency physicians conveniently obtain
The medical record information of patient is taken, to strive for faster treating for patient.
Fig. 4 is a kind of emergency treatment electronic health record management method flow chart provided by one embodiment of the present invention, as shown in figure 4,
Technical solution provided in an embodiment of the present invention includes：
S410：Emergency treatment electronic medical record system obtains patient's by emergency treatment interface service module from emergency treatment sign acquisition module
Sign data.
S420：The emergency treatment electronic medical record system obtains institute by the emergency treatment interface service module from information management system
State the inspection application information of patient and inspection request information.
S430：The emergency treatment electronic medical record system is obtained by the emergency treatment interface service module from medical image information system
It takes the inspection result information of the patient and the inspection result information of the patient is obtained from clinical laboratory's information system.
S440：The emergency treatment electronic medical record system is based on the sign data, the inspection application information, the inspection Shen
It please information, the inspection result information and inspection result information generation electronic health record
S450：The emergency treatment electronic medical record system obtains the emergency physicians based on described from described information management system
The prescription information of information input in electronic health record, and the prescription information is added in the electronic health record.
Wherein, the information in the electronic health record includes the sign data, the inspection result information and the inspection
At least one of in result information.
S460：The emergency treatment electronic medical record system manages system to described information by the emergency treatment interface service module and sends out
Consultation of doctors application information is sent, wherein, carry the information of the patient in the consultation of doctors application information.
S470：Described information manages system when receiving the operation of consultant's opening consultation of doctors application information, leads to
The request that the emergency treatment helper module is called to check the patient electronic medical record to emergency treatment electronic medical record system transmission is crossed, and
It receives the electronic health record for the patient that the emergency treatment electronic medical record system is sent and carries out the electronic health record of the patient
It shows to be supplied to consultant.
S480：Described information manage system when receive consultant open it is described the consultation of doctors application information operation when pass through
The emergency treatment helper module is called to check the request of the care to nursing system transmission, and receives the urgency
It examines the nursing information of the patient of electronic medical record system transmission and is shown to provide by the nursing information of the patient
To consultant.
S490：Described information manages system by the way that the emergency treatment helper module is called to obtain the consultant based on described
The consultation of doctors opinion of electronic health record and/or the nursing information input of patient.
Emergency treatment electronic medical record system described in S491 obtains the consultation of doctors opinion from the emergency treatment helper module, and by the meeting
Opinion is examined to be added in the electronic health record.
Note that it above are only presently preferred embodiments of the present invention and institute's application technology principle.It will be appreciated by those skilled in the art that
The invention is not restricted to specific embodiment described here, can carry out for a person skilled in the art various apparent variations,
It readjusts and substitutes without departing from protection scope of the present invention.Therefore, although being carried out by above example to the present invention
It is described in further detail, but the present invention is not limited only to above example, without departing from the inventive concept, also
It can include other more equivalent embodiments, and the scope of the present invention is determined by scope of the appended claims.
Claims (10)
1. a kind of emergency treatment _ based Patient Records Management Systems, which is characterized in that including：Emergency treatment electronic medical record system, emergency treatment interface service
Module, information management system and emergency treatment sign acquisition module；
The emergency treatment sign acquisition module is connected with external monitor, for gathering the body of patient from the monitor
Levy data；
Described information management system is connected by the emergency treatment interface service module with the emergency treatment electronic medical record system, for root
It is operated according to the application of emergency physicians, generates the inspection application information of the patient and inspection request information；
The emergency treatment electronic medical record system is connected by the emergency treatment interface service module with the emergency treatment sign acquisition module, and
It is connected, used by clinical laboratory's information system of the emergency treatment interface service module respectively with external Medical Imaging System and outside
The trouble is obtained in the sign data that the patient is obtained from the emergency treatment sign acquisition module, and from described information management system
The inspection application information and inspection request information of person and from the medical image information system and clinical laboratory's information system
The inspection result information of the patient and inspection result information and based on the sign data, the inspection Shen are obtained respectively
It please information, the inspection request information, the inspection result information and inspection result information generation electronic health record.
2. emergency treatment _ based Patient Records Management Systems according to claim 1, which is characterized in that
Described information manages system, is additionally operable to obtain prescription of the emergency physicians based on the information input in the electronic health record
Information；Wherein, the information in the electronic health record includes the sign data, the inspection result information and the inspection result
At least one of in information；
The emergency treatment electronic medical record system is additionally operable to obtain the prescription information from described information management system, and by described in
Prescription information is added in the electronic health record.
3. emergency treatment _ based Patient Records Management Systems according to claim 1, which is characterized in that
Described information manages system, is additionally operable to obtain the information in the electronic health record, and based on the letter in the electronic health record
Breath recommends corresponding prescription information；Information in the electronic health record include the sign data, the inspection result information and
At least one of in the inspection result information；
The emergency treatment electronic medical record system is additionally operable to obtain the prescription information from described information management system, and by described in
Prescription information is added in the electronic health record.
4. emergency treatment _ based Patient Records Management Systems according to claim 1, which is characterized in that emergency treatment helper module is further included,
The emergency treatment electronic medical record system is additionally operable to manage system transmission to described information by the emergency treatment interface service module
It holds a consultation application information, wherein, carry the information of the patient in the consultation of doctors application information；
Described information management system is connected with the emergency treatment helper module, and consultant ought be received by, which being additionally operable to, opens the consultation of doctors
During the operation of application information, by the way that the emergency treatment helper module is called to check the trouble to emergency treatment electronic medical record system transmission
The request of person's electronic health record, and receive the electronic health record for the patient that the emergency treatment electronic medical record system is sent and by institute
The electronic health record for stating patient is shown to be supplied to consultant.
5. emergency treatment _ based Patient Records Management Systems according to claim 4, which is characterized in that nursing system is further included,
The nursing system, for storing the nursing information of the patient；
Described information manages system, is additionally operable to, when the operation for receiving consultant's opening consultation of doctors application information, pass through tune
The request of the care is checked to nursing system transmission, and receive the emergency treatment with the emergency treatment helper module
Electronic medical record system send the patient nursing information and the nursing information of the patient is shown to be supplied to
Consultant；
Described information manages system, is additionally operable to be based on the trouble by the way that the emergency treatment helper module is called to obtain the consultant
The consultation of doctors opinion of electronic health record and/or the nursing information input of person.
6. emergency treatment _ based Patient Records Management Systems according to claim 5, which is characterized in that
The emergency treatment electronic medical record system is additionally operable to obtain the consultation of doctors opinion from the emergency treatment helper module, and by the meeting
Opinion is examined to be added in the electronic health record.
7. a kind of emergency treatment electronic health record management method, which is characterized in that including：
Emergency treatment electronic medical record system obtains the sign data of patient by emergency treatment interface service module from emergency treatment sign acquisition module；
The emergency treatment electronic medical record system obtains the patient's by the emergency treatment interface service module from information management system
Check application information and inspection request information；
The emergency treatment electronic medical record system obtains the trouble by the emergency treatment interface service module from medical image information system
The inspection result information of person and the inspection result information that the patient is obtained from clinical laboratory's information system；
The emergency treatment electronic medical record system is based on the sign data, the inspection application information, the inspection request information, institute
State inspection result information and inspection result information generation electronic health record.
8. emergency treatment electronic health record management method according to claim 7, which is characterized in that further include：
The emergency treatment electronic medical record system obtains the emergency physicians from described information management system and is based on the electronic health record
In information input prescription information, and the prescription information is added in the electronic health record；
Wherein, the information in the electronic health record includes the sign data, the inspection result information and the inspection result
At least one of in information.
9. emergency treatment electronic health record management method according to claim 7, which is characterized in that further include：
The emergency treatment electronic medical record system manages system to described information by the emergency treatment interface service module and sends consultation of doctors Shen
Please information, wherein, carry the information of the patient in the consultation of doctors application information；
Described information manages system when receiving the operation of consultant's opening consultation of doctors application information, by described in calling
Emergency treatment helper module checks the request of the patient electronic medical record to emergency treatment electronic medical record system transmission, and receives the urgency
It examines the electronic health record of the patient of electronic medical record system transmission and is shown to provide by the electronic health record of the patient
To consultant；
Described information manages system when receiving the operation of consultant's opening consultation of doctors application information, by described in calling
Emergency treatment helper module checks the request of the care to nursing system transmission, and receives the emergency treatment electronics disease
It goes through the nursing information of the patient of system transmission and is shown the nursing information of the patient consultation of doctors is supplied to cure
It is raw；
Described information manages system by the way that the emergency treatment helper module is called to obtain the electricity of the consultant based on the patient
Sub- case history and/or the consultation of doctors opinion of nursing information input.
10. emergency treatment electronic health record management method according to claim 9, which is characterized in that
The emergency treatment electronic medical record system obtains the consultation of doctors opinion from the emergency treatment helper module, and the consultation of doctors opinion is added
It is added in the electronic health record.
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| CN201711431091.4A CN108122601A (en) | 2017-12-26 | 2017-12-26 | A kind of emergency treatment _ based Patient Records Management Systems and management method |
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| CN108877877A (en) * | 2018-06-11 | 2018-11-23 | 吕传柱 | A kind of information registration management system and method |
| CN110462743A (en) * | 2018-12-06 | 2019-11-15 | 深圳市全息医疗科技有限公司 | A kind of _ based Patient Records Management Systems and method |
| CN111899824A (en) * | 2020-02-04 | 2020-11-06 | 广州市行心信息科技有限公司 | Self-service diagnosis and treatment system based on rule and big data analysis |
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Application publication date: 20180605 |