CN108922586A - Electronic medical record system, electronic health record management method and medical three records instrument - Google Patents
Electronic medical record system, electronic health record management method and medical three records instrument Download PDFInfo
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- CN108922586A CN108922586A CN201810467335.2A CN201810467335A CN108922586A CN 108922586 A CN108922586 A CN 108922586A CN 201810467335 A CN201810467335 A CN 201810467335A CN 108922586 A CN108922586 A CN 108922586A
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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
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Abstract
The invention discloses electronic medical record system, electronic health record management method and medical three records instrument, the system includes SOAP table, subject data obtains module and objective materials obtain module, and the SOAP table includes at least the subject data recording unit for recording subject data acquired in the subject data acquisition module and records the objective materials recording unit that the objective materials obtain objective materials acquired in module.In electronic medical record system of the invention, electronic health record management method and medical three records instrument, module is obtained by subject data and objective materials obtain module and obtain medical care data and record into SOAP table, the automation typing of medical care data is realized, doctor's working efficiency is improved.
Description
Technical field
The present invention relates to e-health field more particularly to a kind of electronic medical record system, electronic health record management method and
Medical three records instrument.
Background technique
A portion content of medical information is to case history electronization, and electronic health record is appointed around the daily diagnosis and treatment of doctor
Business, it is an increasingly numerous and jumbled complex system that main core, which is record, disposition, prescription, inspection,.For a individually disease
Record is gone through, doctor needs to complete the typing work on basis, and the signal for being limited by traditional Medical Devices is sent and access electronics disease
The limitation of the connection type of system is gone through, at present for the typing of basic objective data, such as：Temperature pulse respiration, blood oxygen, blood pressure
It is required on the one hand increase the triviality of clinical position by manual typing, on the other hand do not embody electronic device works
Efficiency.
Summary of the invention
The technical problem to be solved in the present invention is that providing a kind of improved electronic medical record system, electronic health record manager
Method and medical three records instrument.
The technical solution adopted by the present invention to solve the technical problems is：A kind of electronic medical record system, including SOAP are provided
Table, subject data obtain module and objective materials and obtain module, and the SOAP table, which includes at least, to be recorded the subject data and obtain
It the subject data recording unit of subject data acquired in modulus block and records the objective materials and obtains acquired in module
The objective materials recording unit of objective materials.
Preferably, the system also includes portable terminals, and the portable terminal includes objective materials acquisition module, for adopting
Collect the objective materials.
Preferably, the objective materials acquisition module includes
Vital sign acquisition module, for acquiring vital sign data；And/or
Ultrasound acquisition module, for acquiring ultrasonic image data；And/or
Acquisition module is auscultated, for acquiring electronic auscultation data；And/or
Ear nose sight glass acquisition module, for acquiring ear nose sight glass data；And/or
Biochemical acquisition module, for acquiring physicochemical data；And/or
Blood cell collection module, for acquiring blood cell count evidence；And/or
Urine capture module, for acquiring urine data；
The objective materials include the vital sign data, and/or the ultrasonic image data, and/or the electronics
Auscultate data, and/or the ear nose sight glass data, and/or the physicochemical data, and/or blood cell count evidence, and/or institute
State urine data.
Preferably, each data in the objective materials correspond to unique data type identification, and the objective materials obtain
Modulus block is also used to the corresponding position inserted each data according to the unique data type identification in the SOAP table.
Preferably, the system also includes patient stratification's modules, for being recorded according to the objective materials recording unit
The objective materials in, the weight score of each data and state of an illness score calculate a total score, according to the total score
Patient is classified.
A kind of electronic health record management method is also provided, executes following steps using aforementioned electronic medical records system：
Subject data obtains module and obtains subject data；
Objective materials obtain module and obtain objective materials；
SOAP table records the subject data and the objective materials.
Preferably, the electronic health record management method further includes：The objective materials are acquired using portable terminal, including：
Acquire vital sign data；And/or
Acquire ultrasonic image data；And/or
Acquire electronic auscultation data；And/or
Acquire ear nose sight glass data；And/or
Acquire physicochemical data；And/or
Acquire blood cell count evidence；And/or
Acquire urine data；
The objective materials include the vital sign data, and/or the ultrasonic image data, and/or the electronics
Auscultate data, and/or the ear nose sight glass data, and/or the physicochemical data, and/or blood cell count evidence, and/or institute
State urine data.
Preferably, each data in the objective materials correspond to unique data type identification, the electronic health record pipe
Reason method further includes：The objective materials obtain module and each data are inserted institute according to the unique data type identification
State the corresponding position in SOAP table.
Preferably, the electronic health record management method further includes：The institute recorded according to the objective materials recording unit
State in objective materials, the weight score of each data and state of an illness score calculate a total score, with according to the total score will suffer from
Person is classified.
A kind of medical three records instrument with aforementioned electronic medical records system is also provided.
The beneficial effects of the practice of the present invention is：Electronic medical record system of the invention, electronic health record management method and medical three
It records in instrument, module is obtained by subject data and objective materials obtain module and obtain medical care data and record into SOAP table, it is real
Show the automation typing of medical care data, improves doctor's working efficiency.
Detailed description of the invention
Present invention will be further explained below with reference to the attached drawings and examples, in attached drawing：
Fig. 1 is the schematic illustration of electronic medical record system in some embodiments of the invention；
Fig. 2 is the step schematic diagram of electronic health record management method in some embodiments of the invention.
Specific embodiment
For a clearer understanding of the technical characteristics, objects and effects of the present invention, now control attached drawing is described in detail
A specific embodiment of the invention.
Fig. 1 shows the electronic medical record system in some embodiments of the invention, for automating typing medical care data.This hair
Electronic medical record system in bright some embodiments includes that subject data obtains module 10, objective materials obtain module 20, diagnosis letter
Breath obtains module 30, disposition and diagnosis and treatment plan and obtains module 40, patient stratification's module 50, SOAP table 60 and portable terminal 70, main
Sight data obtains module 10 and obtains module 20 for obtaining objective materials, diagnostic message for obtaining subject data, objective materials
It obtains module 30 and obtains module 40 for obtaining diagnostic message, disposition and diagnosis and treatment plan for obtaining disposition and diagnosis and treatment plan, suffer from
For being classified to patient, portable terminal 70 is used for for acquiring objective materials, SOAP table 60 from above-mentioned person's diversity module 50
All medical care data are obtained in modules and are recorded.
Wherein, SOAP table 60 is for recording all medical care data, the i.e. initial content of medical history record, including S
(subject)：Subject data recording unit 61 records main suit or subjective medical history data；O(object)：Objective materials record
Member 62, records objective medical history, including physical examination and auxiliary instrument inspection and laboratory examination results；A(assessment)：It examines
Disconnected information recording unit 63, records the content of condition assessment, diagnosis and antidiastole；P(plan):Disposition and diagnosis and treatment plan record
Unit 64, record disposition and diagnosis and treatment plan.
Subject data recording unit 61 obtains module 10 with subject data and is connected, and obtains module for recording subject data
Subject data acquired in 10.Objective materials recording unit 62 obtains module 20 with objective materials and is connected, objective for recording
Data obtains objective materials acquired in module 20.
Record of diagnostic information unit 63 is for diagnostic message acquired in record diagnosis data obtaining module 30.It disposes and examines
It treats plan recording unit 64 and obtains disposition and diagnosis and treatment plan acquired in module 40 for recording disposition and diagnosis and treatment plan.
Alternatively, in some embodiments, record of diagnostic information unit 63 and disposition and diagnosis and treatment plan recording unit 64
It can be not provided with.But subject data recording unit 61 and objective materials recording unit 62 that SOAP table 60 includes at least.
Subject data obtains module 10 for obtaining subject data.In some embodiments, subject data obtains module 10
The mode for obtaining subject data can be to be a variety of, for example, recording, being manually entered.
Objective materials obtain module 20 for obtaining objective materials, and the source for obtaining objective materials is mainly portable terminal
70.In some embodiments, the mode of objective materials acquisition module 20 acquisition objective materials can be a variety of, for example, recording, hand
Dynamic typing etc..Objective materials include vital sign data, and/or ultrasonic image data, and/or electronic auscultation data, and/or ear
Nasal speculum data, and/or physicochemical data, and/or blood cell count evidence, and/or urine data.Alternatively, vital sign data
Including temperature pulse respiration, blood pressure, electrocardio, blood oxygen.
In some embodiments, each data in objective materials correspond to unique data type identification, and objective materials obtain
Modulus block 20 is also used to the corresponding position inserted each data according to unique data type identification in SOAP table 60.That is SOAP table
It further include each number of multiple record different types of data in the objective materials recording unit 62 of corresponding objective materials in 60
According to corresponding position, distinguished by unique data type identification in these corresponding positions, so that matched data are recorded in
Corresponding position.
Diagnostic message obtains module 30 for obtaining diagnostic message and being sent to record of diagnostic information unit 63.Preferably,
Diagnostic message is by doctor's analysis and assessment and typing.Disposition and diagnosis and treatment plan obtain module 40 for obtaining disposition and diagnosis and treatment plan simultaneously
It is sent to disposition and diagnosis and treatment plan recording unit 64.Preferably, disposition and diagnosis and treatment plan are by doctor's plan and typing.
Portable terminal 70 is for acquiring objective materials.Portable terminal 70 obtains module 20 with objective materials and is connected, and wraps
Include the objective materials acquisition module 71 for acquiring objective materials.Objective materials acquisition module 71 includes：Vital sign acquires mould
Block, for acquiring vital sign data；And/or ultrasound acquisition module, for acquiring ultrasonic image data；And/or auscultation acquisition
Module, for acquiring electronic auscultation data；And/or ear nose sight glass acquisition module, for acquiring ear nose sight glass data；And/or it is raw
Change acquisition module, for acquiring physicochemical data；And/or blood cell collection module, for acquiring blood cell count evidence；And/or urine
Acquisition module, for acquiring urine data.Objective materials include vital sign data, and/or ultrasonic image data, and/or electricity
Son auscultation data, and/or ear nose sight glass data, and/or physicochemical data, and/or blood cell count evidence, and/or urine data.More than
Each functional module can be common have acquisition objective materials function module, be not particularly limited herein, as long as can be real
Existing correlation function.Alternatively, auscultation acquisition module can be electronic auscultation device.Ear nose sight glass acquisition module can be digital
Ear, nasal speculum.It is to be appreciated that the modules in objective materials acquisition module 71 can be connected to by way of flexible access
70 host of portable terminal, to reduce cost, improve portability.
In some embodiments, it is additionally provided with patient stratification's module 50, is connected with objective materials recording unit 62.Patient
In the objective materials that diversity module 50 is used to be recorded according to objective materials recording unit 62, the weight score of each data and disease
Mutual affection number calculates a total score, to be classified patient according to total score.It should be noted that weight score is according to objective money
Score set by type corresponding to each data in material, for example, weight point bigger with the patient body health factor degree of association
Number is higher.Preferably, the weight score of type corresponding to each data can be weight point 1, weight point in objective materials
2 ... weight divides n.State of an illness score is in objective materials in type corresponding to each data, the score of coincident with severity degree of condition,
For example, the state of an illness is more serious, state of an illness score is higher.Preferably, in objective materials type corresponding to each data state of an illness score
Can for the state of an illness point 1, the state of an illness point 2 ... the state of an illness divides n.Total score is the weighted sum of weight score and state of an illness score, and according to total
It is classified.Preferably, total score=weight divide the 1* state of an illness divide 1+ weight divide the 2* state of an illness points 2 ... weight divides the n* state of an illness to divide n.
Such benefit is that the further development and utilization for digit information can establish the staging hierarchy about patient.Can also sufficiently it send out
The positive effect for waving digit information, on the basis of the vital sign information of acquisition, based on NEWS integrating system, that is, urgent early warning product
Subsystem and automation calculate, according to calculated result to patient carry out severe degree label, be clinician to patient classification at
Offer data basis is provided.
The compatible HLT7 of electronic medical record system and DICOM format in the present embodiment.Electronic health record is attached to ICD-10 coding scheme,
Medical diagnosis on disease can be standardized.
The storage management of electronic medical record system includes in the present embodiment：Newly-built electronic health record can be saved locally, authorization doctor
Case history content can be modified/be supplemented to life；Once doctor confirms the medical record information of institute's typing, then remote server, Yi Shengke are sent to
Inquiry, can not edit and modify.
The logon rights management of electronic medical record system is as follows in the present embodiment：By default three classes permission, respectively cure
Life, assistant, patient.Three can pass through user name or Email accessing system.
Patient's permission：The medical record information based on SOAP table 60 can be checked after logining, and can be downloaded or be printed.
Assistant's permission：After accessing system, achievable following work：Patient identification information's typing generates patient identity identification
Code；Inquire information about doctor；Inquire patient's the past diagnosis records；Case control, for patient assign doctor, while according to reservation/just
Examining order is that doctor establishes medical queue.
Doctor's permission：After completion logs in, achievable following work：Doctor inspects work queue；Newly-built SOAP table 60, doctor
It can typing text information again；Doctor can be according to clinical position, calling functional modules, and system automatic identification information is automatically filled in
60 corresponding position of SOAP table；Doctor has permission supplement/modification/confirmation institute typing medical record information；Doctor can turn patient
It examines, turns to make referrals at corresponding medical practitioner in the form of sending Email；Doctor's calling system resource of having the right is sought remotely
Medical treatment is supported；Doctor can inquire anamnesis information.
In other embodiments of the invention, further includes a kind of medical three records instrument, can be tablet computer.In above-described embodiment
Electronic medical record system as implantation piece standard configuration in this present embodiment it is medical three record instrument on, user booting can start.Doctor
Case history input can be completed on medical three records instrument, transfer three record instrument major functions.The other doctors or patient of authorization are obtained simultaneously
Health records can be browsed in page end.The medical three records instrument of tablet computer formula has powerful information processing capability, can meet doctor
More scenes and the need of work of multitask, it is possible to provide the typing mode of artificial words input and video, audio-frequency information.It is especially convenient
Doctor is in medical scene expansion work immediately.
Under working condition it is medical three record instrument record information upload automatically cloud preservation, increase data preservation safety,
Validity.Cloud service simultaneously provides the platform of data sharing for Telemedicine.
In the medical three records instrument of the present embodiment, the diagnosis records of all medical patients are stored in special database,
It retrieves, call for doctor.Alternatively, also queue of waiting to see the doctor can be established for patient, doctor is facilitated to dispatch.
The medical three records instrument other parts of the present embodiment are consistent with the electronic medical record system in previous embodiment, no longer superfluous herein
It states.
Below in conjunction with electronic health record management method in Fig. 1-2 and some embodiments of the invention to electronics disease in previous embodiment
The working principle for going through system is illustrated.Electronic health record management method in some embodiments of the invention is for automating typing doctor
Shield data, including acquisition, acquisition, filling, classification, recording step.
Acquisition step is as follows：
Objective materials are acquired using portable terminal 70, including：Acquire vital sign data；And/or acquisition ultrasonic image number
According to；And/or acquisition electronic auscultation data；And/or acquisition ear nose sight glass data；And/or acquisition physicochemical data；And/or acquisition blood
Cell data；And/or acquisition urine data.Objective materials include vital sign data, and/or ultrasonic image data, and/or electricity
Son auscultation data, and/or ear nose sight glass data, and/or physicochemical data, and/or blood cell count evidence, and/or urine data.
Obtaining step is as follows：
Subject data obtains module 10 and obtains subject data.In some embodiments, subject data obtains module 10 and obtains
The mode of subject data can be to be a variety of, for example, recording, being manually entered.
Objective materials obtain module 20 and obtain objective materials.Its source for obtaining objective materials is mainly portable terminal 70.
In some embodiments, it can be a variety of that objective materials, which obtain module 20 and obtain the mode of objective materials, for example, recording, manually
Typing etc..
Diagnostic message obtains module 30 and obtains diagnostic message.Preferably, diagnostic message is by doctor's analysis and assessment and typing.
Disposition and diagnosis and treatment plan obtain module 40 and obtain disposition and diagnosis and treatment plan.Preferably, disposition and diagnosis and treatment plan are by curing
Livelihood is drawn and typing.
Steps are as follows for filling：
In some preferred embodiments, each data in objective materials correspond to unique data type identification.Objective money
Material obtains the corresponding position that module 20 is inserted each data also according to unique data type identification in SOAP table 60.That is SOAP table
It further include each number of multiple record different types of data in the objective materials recording unit 62 of corresponding objective materials in 60
According to corresponding position, distinguished by unique data type identification in these corresponding positions, so that matched data are recorded in
Corresponding position.Alternatively, filling step can be not provided with.
Classification step is as follows：
Alternatively, in the objective materials that patient stratification's module 50 is recorded also according to objective materials recording unit 62, respectively
The weight score and state of an illness score of a data calculate a total score, to be classified patient according to total score.It should be noted that
Weight score is score set by the type according to corresponding to data each in objective materials, for example, with patient body health
Correlate degree is bigger, and weight score is higher.Preferably, the weight score of type corresponding to each data can in objective materials
Think weight point 1, weight points 2 ... weight divides n.State of an illness score is in objective materials in type corresponding to each data, disease
The score of feelings severity, for example, the state of an illness is more serious, state of an illness score is higher.Preferably, in objective materials corresponding to each data
Type state of an illness score can for the state of an illness point 1, the state of an illness point 2 ... the state of an illness divides n.Total score is weight score and state of an illness score
Weighted sum, and be classified according to total score.Preferably, total score=weight divide the 1* state of an illness divide 1+ weight divide the 2* state of an illness points 2 ...
Weight divides the n* state of an illness to divide n.Such benefit is the further development and utilization for digit information, can establish point about patient
Grade system.The positive effect that digit information can also be given full play to is integrated on the basis of the vital sign information of acquisition based on NEWS
System, that is, urgent early warning integrating system and automation calculate, and severe degree label are carried out to patient according to calculated result, for clinic
Doctor disposes patient classification and provides data basis.Alternatively, classification step can be not provided with.
Recording step is as follows：
Finally, SOAP table 60 records subject data, objective materials, diagnostic message and disposition and diagnosis and treatment plan.
In the present embodiment in the other parts and previous embodiment of electronic health record management method electronic medical record system it is suitable,
Details are not described herein again.
The above is only a preferred embodiment of the present invention, protection scope of the present invention is not limited merely to above-mentioned implementation
Example, all technical solutions belonged under thinking of the present invention all belong to the scope of protection of the present invention.It should be pointed out that for the art
Those of ordinary skill for, several improvements and modifications without departing from the principles of the present invention, these improvements and modifications
Also it should be regarded as protection scope of the present invention.
Claims (10)
1. a kind of electronic medical record system, which is characterized in that obtain module (10), Yi Jike including SOAP table (60), subject data
Sight data obtains module (20), and the SOAP table (60), which includes at least, to be recorded acquired in subject data acquisition module (10)
It the subject data recording unit (61) of subject data and records the objective materials and obtains objective money acquired in module (20)
The objective materials recording unit (62) of material.
2. electronic medical record system according to claim 1, which is characterized in that the system also includes portable terminal (70),
The portable terminal (70) includes objective materials acquisition module (71), for acquiring the objective materials.
3. electronic medical record system according to claim 2, which is characterized in that the objective materials acquisition module (71) includes
Vital sign acquisition module, for acquiring vital sign data；And/or
Ultrasound acquisition module, for acquiring ultrasonic image data；And/or
Acquisition module is auscultated, for acquiring electronic auscultation data；And/or
Ear nose sight glass acquisition module, for acquiring ear nose sight glass data；And/or
Biochemical acquisition module, for acquiring physicochemical data；And/or
Blood cell collection module, for acquiring blood cell count evidence；And/or
Urine capture module, for acquiring urine data；
The objective materials include the vital sign data, and/or the ultrasonic image data, and/or the electronic auscultation
Data, and/or the ear nose sight glass data, and/or the physicochemical data, and/or the blood cell count evidence, and/or the urine
Liquid data.
4. electronic medical record system according to claim 3, which is characterized in that each data in the objective materials are right
Answer unique data type identification, the objective materials obtain module (20) and are also used to institute according to the unique data type identification
State the corresponding position that each data are inserted in the SOAP table (60).
5. electronic medical record system according to claim 4, which is characterized in that the system also includes patient stratification's modules
(50), in the objective materials for being recorded according to the objective materials recording unit (62), the power of each data
Weight score and state of an illness score calculate a total score, to be classified patient according to the total score.
6. a kind of electronic health record management method, which is characterized in that utilize the described in any item electronic medical record systems of claim 1-5
Execute following steps：
Subject data obtains module (10) and obtains subject data；
Objective materials obtain module (20) and obtain objective materials；
SOAP table (60) records the subject data and the objective materials.
7. electronic health record management method according to claim 6, which is characterized in that the electronic health record management method is also wrapped
It includes：The objective materials are acquired using portable terminal (70), including：
Acquire vital sign data；And/or
Acquire ultrasonic image data；And/or
Acquire electronic auscultation data；And/or
Acquire ear nose sight glass data；And/or
Acquire physicochemical data；And/or
Acquire blood cell count evidence；And/or
Acquire urine data；
The objective materials include the vital sign data, and/or the ultrasonic image data, and/or the electronic auscultation
Data, and/or the ear nose sight glass data, and/or the physicochemical data, and/or the blood cell count evidence, and/or the urine
Liquid data.
8. electronic health record management method according to claim 7, which is characterized in that each data in the objective materials
Unique data type identification is corresponded to, the electronic health record management method further includes：The objective materials obtain module (20) root
Each data are inserted to the corresponding position in the SOAP table (60) according to the unique data type identification.
9. electronic health record management method according to claim 8, which is characterized in that the electronic health record management method is also wrapped
It includes：In the objective materials recorded according to the objective materials recording unit (62), the weight score of each data
And state of an illness score calculates a total score, patient to be classified according to the total score.
10. a kind of medical three records instrument with any one of the claim 1-5 electronic medical record system.
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Application publication date: 20181130 |