CN108564992A - A kind of electronic health record method for sorting and system - Google Patents
A kind of electronic health record method for sorting and system Download PDFInfo
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- CN108564992A CN108564992A CN201810340482.3A CN201810340482A CN108564992A CN 108564992 A CN108564992 A CN 108564992A CN 201810340482 A CN201810340482 A CN 201810340482A CN 108564992 A CN108564992 A CN 108564992A
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- Prior art keywords
- patient
- case history
- data
- electronic health
- health record
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- G—PHYSICS
- G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H10/00—ICT specially adapted for the handling or processing of patient-related medical or healthcare data
- G16H10/60—ICT specially adapted for the handling or processing of patient-related medical or healthcare data for patient-specific data, e.g. for electronic patient records
Abstract
The present invention discloses a kind of electronic health record method for sorting, including：Patient is selected from Patient list；Whether Manual arranging case historyIf so, into the Manual arranging page；Edit case history；If it is not, selecting the diagnosis and treatment data needed from the diagnosis and treatment data of hospital；Case history is checked in preview；Confirm case history；It preserves and generates case history.Invention additionally discloses a kind of electronic health record clearing systems, including：Medical data base, image database, electronic medical record system, the electronic medical record system are communicated to connect with the medical data base, the image database respectively.A kind of electronic health record method for sorting disclosed by the invention and system, by the way that all previous diagnosis and treatment data of patient are classified, quickly and easily extract emphasis and are organized into case history on the basis of being manually entered patient data.
Description
Technical field
The present invention relates to data sharing fields, and in particular to a kind of electronic health record method for sorting and system.
Background technology
Currently, the Collator Mode of case history be typically medical personnel person patient data is collected and is organized into PPT or
WORD documents, or patient data is manually filling in case history software using some softwares, such operation meets certain need
It asks, still, such mode arranges the inefficiency of medical history information, and it is big to be manually entered error probability, searches patient history and examines
It is cumbersome to treat data, the progression of the disease situation of patient can not be restored well.
So, it is necessary to a kind of electronic health record method for sorting and system are proposed, on the basis for being manually entered patient data
On, by the way that all previous diagnosis and treatment data of patient are classified, quickly and easily extracts emphasis and be organized into case history.
Invention content
In view of above-mentioned deficiencies of the prior art, the purpose of the present invention is to provide a kind of electronic health record method for sorting and it is
System, by the way that all previous diagnosis and treatment data of patient are classified, quickly and easily extracts weight on the basis of being manually entered patient data
Point is organized into case history, aggregates into patient data overall picture.
To achieve the above object, the present invention adopts the following technical scheme that.
The present invention provides a kind of electronic health record method for sorting, including：
Patient is selected from Patient list；
Whether Manual arranging case history
If so, into the Manual arranging page；Edit case history；
If it is not, selecting the diagnosis and treatment data needed from the diagnosis and treatment data of hospital；
Case history is checked in preview；
Confirm case history；
It preserves and generates case history.
Wherein, the step selects the diagnosis and treatment data needed from the diagnosis and treatment data of hospital, including：
Obtain all previous electronic health record of patient；
Obtain all previous audit report of patient；
Obtain all previous survey report of patient；
Obtain all previous diagnosis and treatment data of patient.
Wherein, the step obtains all previous electronic health record of patient, including：
Select electronic health record data；
Electronic health record data are labeled.
Wherein, the step obtains all previous audit report of patient, including：
Select audit report data；
Image data is operated.
Wherein, the step obtains all previous survey report of patient, including：
Selection check data reporting；
Choose exception item, important references item.
Wherein, the step obtains all previous diagnosis and treatment data of patient.Including：
Select the doctor's advices of all previous diagnosis and treatment, operation record, anesthesia record；
Choose doctor's advice item.
Wherein, the step editor case history includes：
Add title, content；
Upload image picture；
Add attachment.
The present invention also provides a kind of electronic health record clearing systems, including：Medical data base, image database, electronic health record
System, the electronic medical record system are communicated to connect with the medical data base, the image database respectively.
Wherein, the electronic medical record system further includes selecting module, the diagnosis and treatment data for selecting to need.
Wherein, the electronic medical record system further includes locating module, for being positioned into row headers.
Compared with prior art, the present invention has the advantages that：
A kind of electronic health record method for sorting provided by the invention and system, on the basis of patient data is manually entered,
By the way that all previous diagnosis and treatment data of patient are classified, quickly and easily extracts emphasis and be organized into case history, aggregate into patient data overall picture.
Description of the drawings
Fig. 1 is the flow diagram of one embodiment of the invention electronic health record method for sorting；
Fig. 2 is the flow diagram of one embodiment of the invention electronic health record method for sorting；
Fig. 3 is the flow diagram of another embodiment of the present invention electronic health record method for sorting；
Fig. 4 is the flow diagram of another embodiment of the present invention electronic health record method for sorting；
Fig. 5 is the flow diagram of another embodiment of the present invention electronic health record method for sorting；
Fig. 6 is the flow diagram of another embodiment of the present invention electronic health record method for sorting；
Fig. 7 is the flow diagram of one embodiment of the invention electronic health record method for sorting；
Fig. 8 is the control block diagram of one embodiment of the invention electronic health record clearing system.
Specific implementation mode
Embodying the exemplary embodiment of feature of present invention and advantage will in detail describe in above specification.It should be understood that
Various variations can be had in different embodiments by being the present invention, neither be departed from the scope of the present invention, and therein
Illustrate and illustrate inherently to be illustrated as being used, rather than to limit the present invention.
Below in conjunction with attached drawing, invention is further explained.
As shown in Figure 1, Fig. 1 is the flow diagram of one embodiment of the invention electronic health record method for sorting.The electricity of the present invention
Sub- medical record management method.Include the following steps：
Step S101：Patient is selected from Patient list.Medical personnel selects to need from medical Patient list whole
Manage the patient of case history.Medical personnel can check the trouble that will be gone to a doctor of having gone to a doctor and registered on _ based Patient Records Management Systems
The information of person.Who patient assessment medical personnel needs for, or when needing to arrange the case history of who patient, in Patient list
Middle selection patient carries out case history arrangement.
Step S102：Whether Manual arranging case historyMedical personnel chooses whether to need Manual arranging case history.It needs to illustrate
, Manual arranging case history refers to being manually entered the information and diagnosis information of patient in _ based Patient Records Management Systems.
If so, entering step S104：Into the Manual arranging page.If medical personnel selects Manual arranging case history,
Then enter the Manual arranging page.In the Manual arranging page, medical personnel is manually filling the information and diagnosis information of patient.
Step S105：Edit case history.After step S104, medical personnel edits the relevant information of case history, and can more than
Single checklist writes audit report, uploads image picture and be labeled etc..
If it is not, then entering step S103：The diagnosis and treatment data needed are selected from the diagnosis and treatment data of hospital.If medical work
Person does not select Manual arranging case history, then enters the fast finishing case history page, and medical personnel consults all previous diagnosis and treatment data of patient,
And crucial data is therefrom selected to be put into case history.For example, selection admission records, medical history, image data, doctor's advice etc. data,
It can be labeled, be selected, sectional drawing etc., and can by the case history that is arranging now of deposit in.
Step S106：Case history is checked in preview.It, can be pre- after being arranged to case history, and after filling in case history related content
Entirety of looking at checks case history content, and can carry out positioning to case history title and check.
Step S107：Confirm case history.After checking that case history is errorless, case history is confirmed.It should be noted that establishing case history
When, need the finishing time plus case history, collator, responsible doctor etc. and the relevant information of case history.
Step S108：It preserves and generates case history.After confirming case history, case history is preserved and generates, and upload to electronic health record
It is stored in clearing system.
As shown in Fig. 2, Fig. 2 is the flow diagram of one embodiment of the invention electronic health record method for sorting.In the present invention
Step S103 further includes：
Step S1031：Obtain all previous electronic health record of patient.In step S103, fast finishing is carried out to case history, is being arranged
In the process, need all previous electronic health record for obtaining patient can after electronic health record clearing system of the present invention, input patient's name
To obtain all previous electronic health record of patient.Medical personnel gets all previous electronics of patient when arranging the electronic health record of patient
After case history, it can be selected from all previous electronic health record of patient in the electronic health record that the content needed is arranged to this.
Step S1032：Obtain all previous audit report of patient.In the electronic health record clearing system of the present invention, patient is inputted
After information, all previous audit report of patient can be obtained, when arranging case history, can be selected from all previous audit report of patient
With the important indicator data and abnormal index data obtained in audit report.
Step S1033：Obtain all previous survey report of patient.After inputting patient information, all previous inspection of patient can be obtained
Report is tested, the index of inspection result or selection check results abnormity that certain examines project is selected or choose.
Step S1034：Obtain all previous diagnosis and treatment data of patient.Doctor's advice, operation record under the acquisition all previous diagnosis and treatment of patient, fiber crops
Liquor-saturated record etc. data, and it can be selected and is marked.
It should be noted that having multiple diagnosis and therapy recording if necessary to the patient for arranging case history, then selection can be switched and repeatedly examine
Diagnosis and treatment data under treating.
As shown in figure 3, Fig. 3 is the flow diagram of another embodiment of the present invention electronic health record method for sorting.The present invention walks
Suddenly S1031 includes：
Step S10311：Select electronic health record data.When arranging electronic health record, selecting patient, certain is examined medical personnel
All kinds of electronic health record contents under treating.For example, the main suit in the admission records of the last diagnosis and treatment of selection and present illness history, reselection
The admission records being once hospitalized earliest and main suit and for the first time the case history feature in the course of disease, and can and exist in the case history arranged.
Step S10312：Electronic health record data are labeled.It, can be to electricity after getting all previous electronic health record of patient
The data of sub- case history are labeled.For example, being labeled to the course of disease in certain electronic health record.The concrete mode of mark can be
Overstriking, mark are red etc..
As shown in figure 4, Fig. 4 is the flow diagram of another embodiment of the present invention electronic health record method for sorting.The present invention walks
Suddenly S1032 includes：
Step S10321：Select audit report data.If patient has multiple diagnosis and therapy recording, switching to check that patient is all previous and examine
Audit report under treating, can select audit report, choose important referential data.And it is possible to have access to audit report
In image file, the important references part in image file can be selected.
Step S10322：Image data is operated.When having access to image fat file, disease can be carried out to image file
Stove mark, linear measure longimetry, sectional drawing be stored in case history etc. operation.
As shown in figure 5, Fig. 5 is the flow diagram of another embodiment of the present invention electronic health record method for sorting.Step S1033
Including：
Step S10331：Selection check data reporting.If patient has multiple diagnosis and therapy recording, it can switch and check and select
Survey report under all previous diagnosis and treatment of patient while selection as a result, pop up the index of inspection result exception, medical personnel can
It is chosen with the index to these inspection results exception.
Step S10332：Choose exception item, important references item.Medical personnel can choose when checking survey report
The index of inspection result exception chooses the project of inspection result exception, while can choose important in survey report
Reference items add it in the case history arranged.
As shown in fig. 6, Fig. 6 is the flow diagram of another embodiment of the present invention electronic health record method for sorting.The present invention walks
Suddenly S1034 includes：
Step S10341：Select the doctor's advices of all previous diagnosis and treatment, operation record, anesthesia record.If patient has multiple diagnosis and therapy recording,
It is changeable to check and select doctor's advice under all previous diagnosis and treatment of patient, operation record, anesthesia record etc. data, and be added to just
In the case history of arrangement.
Step S10342：Choose doctor's advice item.Medical personnel can choose doctor's advice during arranging electronic health record
, doctor's advice item is added in the case history arranged or as important reference frame, it can also be to doctor's advice item into rower
Note.
As shown in fig. 7, Fig. 7 is the flow diagram of one embodiment of the invention electronic health record method for sorting.Step of the present invention
S105 further includes：
Step S1051：Add title, content.When editing case history, medical personnel can add certainly according to actual needs
It defines title and adds content according to actual needs.
Step S1052：Upload image picture.Voluntary labor service author can be added as needed on picture when arranging case history, branch
Online preview is held, also supports the instruments with camera function such as computer end connection high photographing instrument, mobile phone, and supports directly upper blit
Piece.In addition, also supporting OCR character identification functions, image content is converted into word content.The page of Manual arranging includes interior
Hold the modules such as frame, such as electronic health record, audit report, survey report.The image picture added manually only needs to comply with standard
DICOM, DICOM, that is, digital imaging and communications in medicine are the international standard protocols of medical image and relevant information, in the present invention
Image identification facility energy automatic identification image sequence.
Step S1053：Add attachment.Voluntary labor service author can add the attached of the forms such as picture, document according to actual needs
The document of part, such as WORD, EXCEL, PPT, TEXT etc. format, and the online preview of supporting attachment.
As shown in figure 8, Fig. 8 is the control block diagram of one embodiment of the invention electronic health record clearing system.The present invention also provides
A kind of electronic health record clearing system, including medical data base 100, image database 200, electronic medical record system 300, the electronics
Medical records system 300 is communicated to connect with the medical data base 100, the image database 200 respectively.Medical data base 100 is used
It is examined in storage medical diagnostic data, such as electronic health record, audit report, survey report, operation record, anesthesia record etc. medical treatment
Disconnected data.Image database 200 is for storing image data.Electronic medical record system 300 is for filling in electronic health record and arranging electricity
Sub- case history.Electronic health record clearing system can obtain patient's from medical data base 100 and image database 200 in the present invention
All previous medical diagnostic data and image data, and support online arrange.The page of Manual arranging includes content frame, such as electricity
The modules such as sub- case history, audit report, survey report.
The electronic medical record system 300 of the present invention, further includes selecting module, the diagnosis and treatment data for selecting to need, such as is selected
Select electronic health record, selection audit report, selection check report etc..
Electronic medical record system 300 in the electronic health record clearing system of the present invention further includes locating module, for electronics
Title in case history carries out positioning and checks.
It should be noted that electronic health record method for sorting of the present invention and system, are mainly used for obligation of notice worker
For the convenient medical scene for arranging case history such as speech, teaching, the consultation of doctors or case history discussion, scientific research analysis, prepare for medical personnel
Medical presentation provides facility.
In conclusion a kind of electronic health record method for sorting provided by the invention and system, are manually entered by patient data
On the basis of, by the way that all previous diagnosis and treatment data of patient are classified, quickly and easily extracts emphasis and be organized into case history, aggregate into patient
Data overall picture.
Although describing the present invention with reference to exemplary embodiment, it is to be understood that, term used is explanation and example
Property, term and not restrictive.Due to the present invention spirit or essence that can be embodied in a variety of forms without departing from invention,
It should therefore be appreciated that the above embodiment is not limited to any details above-mentioned, and should be spiritual defined by appended claims
Accompanying is all should be with the whole variations and remodeling widely explained, therefore fallen into claim or its equivalent scope in range to weigh
Profit requires to be covered.
Claims (10)
1. a kind of electronic health record method for sorting, which is characterized in that including：
Patient is selected from Patient list；
Whether Manual arranging case history
If so, into the Manual arranging page；Edit case history；
If it is not, selecting the diagnosis and treatment data needed from the diagnosis and treatment data of hospital；
Case history is checked in preview；
Confirm case history；
It preserves and generates case history.
2. according to the method described in claim 1, it is characterized in that, the step selects needs from the diagnosis and treatment data of hospital
Diagnosis and treatment data, including：
Obtain all previous electronic health record of patient；
Obtain all previous audit report of patient；
Obtain all previous survey report of patient；
Obtain all previous diagnosis and treatment data of patient.
3. according to the method described in claim 2, it is characterized in that, the step obtain patient all previous electronic health record, including：
Select electronic health record data；
Electronic health record data are labeled.
4. according to the method described in claim 2, it is characterized in that, the step obtain patient all previous audit report, including：
Select audit report data；
Image data is operated.
5. according to the method described in claim 2, it is characterized in that, the step obtain patient all previous survey report, including：
Selection check data reporting；
Choose exception item, important references item.
6. according to the method described in claim 2, it is characterized in that, the step obtains all previous diagnosis and treatment data of patient.Including：
Select the doctor's advices of all previous diagnosis and treatment, operation record, anesthesia record；
Choose doctor's advice item.
7. according to the method described in claim 1, it is characterized in that, the step editor case history includes：
Add title, content；
Upload image picture；
Add attachment.
8. a kind of electronic health record clearing system, which is characterized in that including：Medical data base, image database, electronic health record system
System, the electronic medical record system are communicated to connect with the medical data base, the image database respectively.
9. system according to claim 8, which is characterized in that the electronic medical record system further includes selecting module, is used for
Select the diagnosis and treatment data needed.
10. according to claim 8 or 9 any one of them systems, which is characterized in that the electronic medical record system further includes positioning
Module, for being positioned into row headers.
Priority Applications (1)
| Application Number | Priority Date | Filing Date | Title |
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| CN201810340482.3A CN108564992A (en) | 2018-04-16 | 2018-04-16 | A kind of electronic health record method for sorting and system |
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| Application Number | Priority Date | Filing Date | Title |
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| CN201810340482.3A CN108564992A (en) | 2018-04-16 | 2018-04-16 | A kind of electronic health record method for sorting and system |
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| CN108564992A true CN108564992A (en) | 2018-09-21 |
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| CN201810340482.3A Pending CN108564992A (en) | 2018-04-16 | 2018-04-16 | A kind of electronic health record method for sorting and system |
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Cited By (1)
| Publication number | Priority date | Publication date | Assignee | Title |
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| CN109271973A (en) * | 2018-11-09 | 2019-01-25 | 天津新开心生活科技有限公司 | Medicine text OCR method and system |
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| US20040243545A1 (en) * | 2003-05-29 | 2004-12-02 | Dictaphone Corporation | Systems and methods utilizing natural language medical records |
| CN105844074A (en) * | 2015-01-30 | 2016-08-10 | 富士胶片株式会社 | Medical support apparatus, method and system for medical care |
| CN105844566A (en) * | 2016-03-25 | 2016-08-10 | 东华软件股份公司 | Electronic medical record filing management system and electronic medical record filing management method |
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Application publication date: 20180921 |
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