CN108182965B - Electronic medical record generation system and method - Google Patents
Electronic medical record generation system and method Download PDFInfo
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- CN108182965B CN108182965B CN201711488655.8A CN201711488655A CN108182965B CN 108182965 B CN108182965 B CN 108182965B CN 201711488655 A CN201711488655 A CN 201711488655A CN 108182965 B CN108182965 B CN 108182965B
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Abstract
The invention provides an electronic medical record generation system, which comprises a template designer, a unit controller, an electronic medical record generator and a template converter, wherein the template designer, the unit controller, the electronic medical record generator and the template converter are used for sequentially carrying out data interaction; the template designer is used for editing initial design data of the electronic medical record template and generating logic control data and interface parameters of the electronic medical record template by butting the database; the unit controller is used for respectively adding unit elements to the initial design data, generating control data, and controlling the data to adjust and control the functional parameters of the electronic medical record template; the electronic medical record generator is used for logically screening the electronic medical record template and loading and generating the electronic medical record according to the control data in the unit controller; the template converter is used for extracting data in the template designer and data in the unit controller, feeding back after analysis and judging whether template conversion is carried out or not. The method has the advantages of neat and controllable typesetting format style interface, sharing in different use units and high operation efficiency.
Description
Technical Field
The invention belongs to the field of medical electronics, and particularly relates to an electronic medical record generation system and method.
Background
The medical record is a main carrier of medical activity information, not only is first-hand information of medical treatment, teaching and scientific research, but also is a basis for comprehensively evaluating the medical quality, technical level and management level of a hospital. The writing requirement format of the medical record is uniform and standard, the semantic expression is accurate, and conditions can be created for strengthening medical quality management and improving the working level of clinical medical treatment, teaching and scientific research.
With the development of medical information technology, electronic medical records are more and more spread for use in medical activities of hospitals, however, in the using process, because the medical record formats are not uniform, the typesetting styles are different, and the requirement of uniform medical record writing formats cannot be met. Due to the fact that the terms, codes and structures of electronic medical records are different among different units, medical record templates of different doctors, different departments and different medical institutions cannot be shared, the same template or similar templates need to be repeatedly designed, the unified and attractive format is affected, and the working efficiency is affected.
Therefore, there is a need for a system and a method for generating an electronic medical record, which can realize neat and controllable typesetting format style interface, can be shared in different use units, and has high operation efficiency.
Disclosure of Invention
The invention aims to provide an electronic medical record generation system and method, which aim to solve the problems of inconvenient typesetting style, difficulty in sharing and low operation efficiency in the prior art.
The invention provides the following technical scheme:
an electronic medical record generation system comprises a template designer, a unit controller, an electronic medical record generator and a template converter, wherein the template designer, the unit controller, the electronic medical record generator and the template converter are used for sequentially carrying out data interaction; the template designer is used for editing initial design data of the electronic medical record template and generating logic control data and interface parameters of the electronic medical record template by butting the database; the unit controller is used for respectively adding unit elements to the initial design data to generate control data, and adjusting and controlling the functional parameters of the electronic medical record template through the control data; the electronic medical record generator is used for logically screening the electronic medical record template in the template designer and loading and generating the electronic medical record according to the control data in the unit controller; the template converter is used for respectively extracting initial design data in the template designer and control data in the unit controller, analyzing the initial design data and the control data, and feeding the analyzed initial design data and the analyzed control data back to the template designer and the unit controller to judge whether template conversion is carried out or not.
Preferably, the initial design data in the stencil designer includes a stencil class, a stencil name, a paper parameter, a page parameter, a limiting factor, a header display, and a digital signature control.
Preferably, the template designer further comprises an electronic medical record template importing module, and the electronic medical record generator further comprises an electronic medical record template exporting module.
Preferably, the unit controller includes a small template management unit, a reference domain management unit, and a unit attribute management unit.
An electronic medical record generation method comprises the following steps: s1, system initialization: newly building or importing an electronic medical record template, and initializing electronic medical record attribute parameters; s2, data loading: loading the electronic medical record template attribute parameters in the step S1 according to preset standards, and generating corresponding logic control parameters and interface parameters; s3, medical record generation: logically screening the attribute parameters in the step S2, loading a corresponding electronic medical record template, comparing historical data of the electronic medical record template, generating a target electronic medical record, and visually displaying the target electronic medical record; in the process of step S2 and step S3, data extraction and analysis are performed synchronously to determine whether to perform template conversion.
Preferably, step S1 further includes importing an electronic medical record template, where the importing of the electronic medical record template includes the following steps: s101, responding to an electronic medical record template file which is selected by a user and needs to be imported by a system; s102, extracting the electronic medical record template file, and converting a file data stream into structural data with a corresponding logical relationship and a structural data relationship; s103, extracting the attribute, the unit element definition, the reference domain definition and the style definition data of the electronic medical record template file from the structural data and storing the data.
Preferably, the step S3 further includes deriving an electronic medical record template, where the deriving of the electronic medical record template includes the following steps: s201, selecting an electronic medical record template needing to derive a patent document; s202, extracting attributes, unit element definitions, reference definitions and style definition data of the electronic medical record template in the step S201, and correspondingly converting structural data with corresponding logical relations; and S203, converting the structural data in the step S202 into data size, generating a user interface, receiving a file path of a medical record template edited and saved by a user, and finishing export.
The invention has the beneficial effects that:
the scheme of the invention can realize the design of various electronic medical record forms by adopting a template designer, a unit controller, an electronic medical record generator and a template converter which interact with each other, without a third-party control; the method and the device separately process the style attribute and the content data, can realize the style and content modification based on the template designer, protect the style from being adjusted by a user under the electronic medical record generator, realize the data adjustment through the template converter, and effectively achieve the flexibility and the integrity of the style of the whole electronic medical record; and the template converter is adopted, so that the sharing work of the electronic medical record among a plurality of using units is favorably realized, and the application range is wide.
Drawings
The accompanying drawings, which are included to provide a further understanding of the invention and are incorporated in and constitute a part of this specification, illustrate embodiments of the invention and together with the description serve to explain the principles of the invention and not to limit the invention. In the drawings:
FIG. 1 is a schematic representation of the process steps of the present invention;
FIG. 2 is a schematic diagram of the system of the present invention;
FIG. 3 is a schematic flow chart of the operation of the present invention;
FIG. 4 is an interface diagram of a stencil designer in an embodiment;
FIG. 5 is an interface diagram of a reference domain management unit in the embodiment;
FIG. 6 is an interface diagram of a small template management unit in an embodiment;
FIG. 7 is an interface diagram of a Unit Attribute management Unit in an embodiment;
FIG. 8 is a flow diagram of electronic medical record template import;
FIG. 9 is a flow diagram of electronic medical record template export;
in the figure: 1. the system comprises a template designer, 2 a unit controller, 3 an electronic medical record generator and 4 a template converter.
Detailed Description
As shown in fig. 1 to 9, an electronic medical record generation system includes a template designer 1, a unit controller 2, an electronic medical record generator 3, and a template converter 4, which perform data interaction in sequence; the template designer 1 is used for editing initial design data of the electronic medical record template and generating logic control data and interface parameters of the electronic medical record template by butting a database; the unit controller 2 is used for respectively adding unit elements to the initial design data to generate control data, and adjusting and controlling functional parameters of the electronic medical record template through the control data; the electronic medical record generator 3 is used for logically screening the electronic medical record templates in the template designer 1 and loading and generating the electronic medical record according to the control data in the unit controller 2; the template converter 4 is used for extracting initial design data in the template designer 1 and control data in the unit controller 2, analyzing the initial design data and the control data, feeding the analyzed initial design data and the analyzed control data back to the template designer 1 and the unit controller 2, and judging whether template conversion is performed or not.
Preferably, the initial design data in the stencil designer 1 includes a stencil class, a stencil name, a paper parameter, a page parameter, a limiting factor, a header display, and a digital signature control. The template designer 1 further comprises an electronic medical record template importing module, and the electronic medical record generator 3 further comprises an electronic medical record template exporting module. The unit controller 2 includes a small template management unit, a reference domain management unit, and a unit attribute management unit.
The generation method based on the electronic medical record comprises the following steps: s1, system initialization: newly building or importing an electronic medical record template, and initializing electronic medical record attribute parameters; s2, data loading: loading the electronic medical record template attribute parameters in the step S1 according to preset standards, and generating corresponding logic control parameters and interface parameters; s3, medical record generation: and logically screening the attribute parameters in the step S2, loading a corresponding electronic medical record template, comparing historical data of the electronic medical record template, generating a target electronic medical record, and visually displaying the target electronic medical record.
Preferably, during the processes of step S2 and step S3, data extraction and analysis are performed synchronously to determine whether to perform template conversion. Step S1 further includes importing an electronic medical record template, where the importing of the electronic medical record template includes the following steps: s101, responding to an electronic medical record template file which is selected by a user and needs to be imported by a system; s102, extracting the electronic medical record template file, and converting a file data stream into structural data with a corresponding logical relationship and a structural data relationship; s103, extracting the attribute, the unit element definition, the reference domain definition and the style definition data of the electronic medical record template file from the structural data and storing the data. In step S3, the method further includes deriving an electronic medical record template, where the deriving of the electronic medical record template includes the following steps: s201, selecting an electronic medical record template needing to derive a patent document; s202, extracting attributes, unit element definitions, reference definitions and style definition data of the electronic medical record template in the step S201, and correspondingly converting structural data with corresponding logical relations; and S203, converting the structural data in the step S202 into data size, generating a user interface, receiving a file path of a medical record template edited and saved by a user, and finishing export.
Specifically, in the implementation and application process, the electronic medical record system automatically screens out the available electronic medical record template range from a data source (hospital database) according to the identity and diagnosis of a patient, determines the electronic medical record template needed to be used through screening and judgment of the template converter 4 according to the instruction of the user, further reads template attributes, unit elements and reference data to generate a visual medical record editing interface, receives user input information to edit a medical record, and completes generation of the electronic medical record.
Therefore, the invention has the advantages of neat and controllable typesetting format style interface, sharing in different use units and high operation efficiency.
Although the present invention has been described in detail with reference to the foregoing embodiments, it will be apparent to those skilled in the art that changes may be made in the embodiments and/or equivalents thereof without departing from the spirit and scope of the invention. Any modification, equivalent replacement, or improvement made within the spirit and principle of the present invention should be included in the protection scope of the present invention.
Claims (4)
1. An electronic medical record generation system is characterized by comprising a template designer, a unit controller, an electronic medical record generator and a template converter, wherein the template designer, the unit controller, the electronic medical record generator and the template converter are used for sequentially carrying out data interaction;
the template designer is used for editing initial design data of the electronic medical record template and generating logic control data and interface parameters of the electronic medical record template by butting the database;
the unit controller is used for respectively adding unit elements to the initial design data to generate control data, and adjusting and controlling the functional parameters of the electronic medical record template through the control data;
the electronic medical record generator is used for logically screening the electronic medical record template in the template designer and loading and generating the electronic medical record according to the control data in the unit controller;
the template converter is used for respectively extracting initial design data in the template designer and control data in the unit controller, analyzing the initial design data and the control data, and feeding the analyzed initial design data and the analyzed control data back to the template designer and the unit controller to judge whether template conversion is carried out or not;
the electronic medical record generation method is characterized by comprising the following steps of:
s1, system initialization: newly building or importing an electronic medical record template, and initializing electronic medical record attribute parameters;
step S1 further includes importing an electronic medical record template, where the importing of the electronic medical record template includes the following steps:
s101, responding to an electronic medical record template file which is selected by a user and needs to be imported by a system;
s102, extracting the electronic medical record template file, and converting a file data stream into structural data with a corresponding logical relationship and a structural data relationship;
s103, extracting the attribute, unit element definition, reference domain definition and style definition data of the electronic medical record template file from the structural data and storing the data;
in step S3, the method further includes deriving an electronic medical record template, where the deriving of the electronic medical record template includes the following steps:
s201, selecting an electronic medical record template needing to derive a patent document;
s202, extracting attributes, unit element definitions, reference definitions and style definition data of the electronic medical record template in the step S201, and correspondingly converting structural data with corresponding logical relations;
s203, converting the structural data in the step S202 into data volume, generating a user interface, receiving a file path of a medical record template edited and stored by a user, and finishing export;
s2, data loading: loading the electronic medical record template attribute parameters in the step S1 according to preset standards, and generating corresponding logic control parameters and interface parameters; in the processes of step S2 and step S3, data extraction and analysis are synchronously performed to determine whether to perform template conversion, respectively;
s3, medical record generation: and logically screening the attribute parameters in the step S2, loading a corresponding electronic medical record template, comparing historical data of the electronic medical record template, generating a target electronic medical record, and visually displaying the target electronic medical record.
2. The electronic medical record generation system as claimed in claim 1, wherein the initial design data in the template designer includes template classification, template name, paper parameters, page parameters, limiting factors, header display and digital signature control.
3. The electronic medical record generation system of claim 2, wherein the template designer further comprises an electronic medical record template import module and the electronic medical record generator further comprises an electronic medical record template export module.
4. The electronic medical record generation system according to claim 1, wherein the unit controller comprises a small template management unit, a reference domain management unit and a unit attribute management unit.
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| Publication number | Priority date | Publication date | Assignee | Title |
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| CN109509515A (en) * | 2018-06-29 | 2019-03-22 | 康美药业股份有限公司 | Electronic health record management method, electronic equipment, storage medium, system |
| CN108648788A (en) * | 2018-07-04 | 2018-10-12 | 莫毓昌 | A kind of rehabilitation medical process management system of semi-structured electronic health record |
| CN112131851B (en) * | 2020-09-03 | 2022-07-29 | 卫宁健康科技集团股份有限公司 | Target electronic medical record template generation method and device |
Citations (4)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN101782935A (en) * | 2009-01-19 | 2010-07-21 | 中国人民解放军第二军医大学 | Electronic medical record system and medical record data parsing and processing method for traditional Chinese medical science |
| CN105678671A (en) * | 2015-12-29 | 2016-06-15 | 北京嘉和美康信息技术有限公司 | Method and apparatus for generation of electronic medical record, mobile terminal and electronic medical record system |
| CN106845054A (en) * | 2015-12-04 | 2017-06-13 | 北大医疗信息技术有限公司 | Electronic health record edit methods and system based on HTML5 |
| CN107463776A (en) * | 2017-07-26 | 2017-12-12 | 深圳市坐标软件开发有限公司 | WEB terminal electronic health record generation method and system are realized based on B/S frameworks |
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Patent Citations (4)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN101782935A (en) * | 2009-01-19 | 2010-07-21 | 中国人民解放军第二军医大学 | Electronic medical record system and medical record data parsing and processing method for traditional Chinese medical science |
| CN106845054A (en) * | 2015-12-04 | 2017-06-13 | 北大医疗信息技术有限公司 | Electronic health record edit methods and system based on HTML5 |
| CN105678671A (en) * | 2015-12-29 | 2016-06-15 | 北京嘉和美康信息技术有限公司 | Method and apparatus for generation of electronic medical record, mobile terminal and electronic medical record system |
| CN107463776A (en) * | 2017-07-26 | 2017-12-12 | 深圳市坐标软件开发有限公司 | WEB terminal electronic health record generation method and system are realized based on B/S frameworks |
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