CN109543957A - The method and apparatus for generating medical record quality inspection report based on data processing - Google Patents
The method and apparatus for generating medical record quality inspection report based on data processing Download PDFInfo
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- CN109543957A CN109543957A CN201811265653.7A CN201811265653A CN109543957A CN 109543957 A CN109543957 A CN 109543957A CN 201811265653 A CN201811265653 A CN 201811265653A CN 109543957 A CN109543957 A CN 109543957A
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- G—PHYSICS
- G06—COMPUTING; CALCULATING OR COUNTING
- G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
- G06Q10/00—Administration; Management
- G06Q10/06—Resources, workflows, human or project management; Enterprise or organisation planning; Enterprise or organisation modelling
- G06Q10/063—Operations research, analysis or management
- G06Q10/0639—Performance analysis of employees; Performance analysis of enterprise or organisation operations
- G06Q10/06395—Quality analysis or management
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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 provides the method and apparatus for generating medical record quality inspection report based on data processing, method comprises determining that the corresponding all data of medical record to quality inspection, all data include medical institutions' information data, geographic information data, user basic information data, medical information data, hospital course information data and medical expense information data；Determine that the corresponding quality inspection rule of medical record, quality inspection rule include at least one of the corresponding quality inspection rule of user basic information, the corresponding quality inspection rule of medical information, the corresponding quality inspection rule of hospital course information quality inspection rule corresponding with medical expense information quality inspection rule according to medical institutions' information data and geographic information data；Quality assessment is carried out to medical record according to quality inspection rule and user basic information data, medical information data, hospital course information data and medical expense information data and obtains the quality inspection report of medical record；Export quality inspection report.Medical record Quality Control efficiency can be improved in the technical solution, realizes the differentiation processing of quality inspection rule.
Description
Technical field
The present invention relates to field of medical technology, more particularly to based on data processing generate medical record quality inspection report method and
Device.
Background technique
Case history, refer to medical worker to the generation of patient disease, the medical treatment such as develop, lapse to, check, diagnose, treat
The record of active procedure and medical worker conclude collected data, arranged, comprehensive analysis and by defined format
With the patient medical health account for requiring writing.Case history requirement medical worker is objective, true, accurate, timely, completely record is suffered from
Person's state of an illness and diagnosis and treatment are passed through.Medical record is that case history is handed in the patient arranged after medical record management mechanism by medical record administrator just
Whole medical data during examining.Medical record Quality Control refers to and carries out quality to first page of illness case in order to guarantee the standardization filled in
The process of inspection.
Currently, generally by manually being given a mark according to international standards of grading to first page of illness case to realize medical record Quality Control, a side
Face, the efficiency manually given a mark are lower；On the other hand, the quality inspection rule in international standards of grading is relatively coarse, for certain special
Regional or special medical institutions, international standards of grading are not appropriate for.
Summary of the invention
The embodiment of the present invention provides the method and apparatus for generating medical record quality inspection report based on data processing, solves artificial root
The not high problem of the low efficiency and applicability given a mark according to international standards of grading.
In a first aspect, providing a kind of method for generating medical record quality inspection report based on data processing, comprising:
Determine the corresponding all data of medical record to quality inspection, all data includes medical institutions' information data, geography
Information data, user basic information data, medical information data, hospital course information data and medical expense information data；
The corresponding quality inspection rule of the medical record is determined according to medical institutions' information data and the geographic information data,
The quality inspection rule includes the corresponding quality inspection rule of user basic information, the corresponding quality inspection rule of medical information, hospital course letter
Cease at least one of corresponding quality inspection rule and the corresponding quality inspection rule of medical expense information quality inspection rule；
According to the quality inspection rule, and, the user basic information data, medical information data, hospital course information
Data and medical expense information data carry out quality assessment to the medical record, obtain the quality inspection report of the medical record；
Export the quality inspection report.
In the embodiment of the present invention, by can determine ground belonging to the medical record according to the corresponding all data of the medical record to quality inspection
Region is managed, the quality inspection rule that then selection is adapted to the geographic area carries out quality assessment to the case history and obtains the quality inspection of the medical record
Report, and quality inspection report is exported, the automatic detection to medical record quality is realized, the efficiency of medical record Quality Control is improved；In addition, with
The geographic area belonging to the quality inspection rule and medical record for carrying out quality assessment is adapted, at the differentiation for realizing quality inspection rule
Reason, so that quality inspection rule can adapt to the specific medical conditions of the geographic area.
With reference to first aspect, in one possible implementation, the quality inspection report includes that the quality inspection rule is corresponding
Each quality inspection project mass fraction and the medical record quality gross score；It is described regular according to the quality inspection, and, it is described
User basic information data, medical information data, hospital course information data and medical expense information data to the medical record into
Row quality assessment obtains the quality inspection report of the medical record, comprising: determine the corresponding each quality inspection project of the quality inspection rule, and
It is determined from the user basic information data, medical information data, hospital course information data and medical expense information data
The corresponding data of each quality inspection project；According to each corresponding quality inspection rule of quality inspection project and each quality inspection project
Corresponding data respectively score to each quality inspection project, obtain the mass fraction of each quality inspection project；By institute
The sum of the mass fraction for stating each quality inspection project is determined as the quality gross score of the medical record.Geographic area is adapted to by determination
The quality inspection rule quality inspection project and the corresponding data of quality inspection project that are included, according to its corresponding quality inspection rule to the matter
Inspection project scores, and realizes the auto-scoring to the medical record；By mass fraction in quality inspection report output quality inspection project and
The quality gross score of medical record can make relevant user (the filling in personnel of such as quality inspection personnel, the medical record) understand the score of the medical record
Situation.
With reference to first aspect, in one possible implementation, the quality inspection report further includes the quality of the medical record
Grade；It is described regular according to the quality inspection, and, the user basic information data, medical information data, hospital course information
Data and medical expense information data carry out quality assessment to the medical record, obtain the quality inspection report of the medical record, further includes: really
Determine the corresponding full marks threshold value of the quality inspection rule and credit rating score threshold, the credit rating score threshold include first point
Number threshold value and the second score threshold, first score threshold are greater than second score threshold；If the quality gross score
For the full marks threshold value, it is determined that the credit rating of the medical record is outstanding；If the quality gross score is not the full marks
Threshold value, it is determined that the quality inspection deduction of points project of the medical record；If the quality gross score is greater than or equal to the first score threshold
Value, and quality inspection deduction of points project is not the first quality inspection project, it is determined that the credit rating of the medical record be it is outstanding, described the
One quality inspection project is to meet the quality inspection project of A intermediate item in international medical record standards of grading；If the quality gross score is less than
One score threshold and be greater than or equal to second score threshold, also, the quality inspection deduction of points project be not first matter
Inspection project, it is determined that the credit rating of the medical record is qualification；If the quality gross score is less than second score threshold,
Or the quality inspection deduction of points project is the first quality inspection project, it is determined that the credit rating of the medical record is unqualified.By right
The quality gross score of medical record and quality inspection deduction of points project are judged, the automatic judgement to the credit rating of medical record may be implemented；It is logical
It crosses and exports the credit rating of medical record in quality inspection report, the credit rating that family understands the medical record can be used, and then can root
The specification situation that medical worker related with the medical record or medical institutions' case history fill in is determined according to the credit rating.
With reference to first aspect, in one possible implementation, the quality inspection report further includes the quality inspection deduction of points item
Purpose type of error；It is described regular according to the quality inspection, and, the user basic information data, are hospitalized at medical information data
Procedural information data and medical expense information data carry out quality assessment to the medical record, obtain the quality inspection report of the medical record,
If further include: quality inspection deduction of points project is the second quality inspection project, it is determined that the type of error of the quality inspection deduction of points project is
Logicality mistake, the second quality inspection project are the quality inspection project do not filled in the medical record, also, the user basic information
Exist and the second quality inspection project in data, medical information data, hospital course information data and medical expense information data
Associated quality inspection project or the corresponding data of item；If the quality inspection deduction of points project is not the second quality inspection project, really
The type of error of the fixed quality inspection deduction of points project is completeness error.Pass through the quality gross score and quality inspection deduction of points project to medical record
Judged, the automatic judgement to the type of error of medical record may be implemented；By type of error that quality inspection is deducted points in quality inspection report
It is exported in announcement, family can be used and understand which quality inspection project in medical record is filled in lack of standardization and the quality inspection project is filled in and do not advised
The reason of model.
With reference to first aspect, in one possible implementation, the output quality inspection report, comprising: described
Quality inspection deduction of points project is marked in a manner of being different from other quality inspection projects in quality inspection report, other described quality inspection items
Mesh is the quality inspection project removed except the quality inspection deduction of points project in the corresponding each quality inspection project of the quality inspection rule；Output pair
The quality inspection report that the quality inspection deduction of points project is marked.It is not it by mark quality score prominent in quality inspection is reported
The quality inspection project of corresponding full marks threshold value navigates to user quickly and fills in nonstandard quality inspection project.
With reference to first aspect, in one possible implementation, the output quality inspection report includes: with report or chart
Form export quality inspection report.This mode is able to use the quality inspection situation that family more intuitively understands medical record.
Second aspect provides a kind of device for generating medical record quality inspection report based on data processing, comprising:
Data determining module, for determining that the corresponding all data of medical record to quality inspection, all data include medical treatment
Organization information data, geographic information data, user basic information data, medical information data, hospital course information data and
Medical expense information data；
Quality inspection rule determining module, for determining institute according to medical institutions' information data and the geographic information data
The corresponding quality inspection rule of medical record is stated, the quality inspection rule includes that the corresponding quality inspection of user basic information is regular, medical information is corresponding
Quality inspection rule, at least one of hospital course information corresponding quality inspection rule quality inspection rule corresponding with medical expense information
Quality inspection rule；
It reports determining module, is used for according to the quality inspection rule, and, the user basic information data, medical information
Data, hospital course information data and medical expense information data carry out quality assessment to the medical record, obtain the medical record
Quality inspection report；
Report output module, for exporting the quality inspection report.
The third aspect, provides another device for generating medical record quality inspection report based on data processing, including processor, deposits
Reservoir and input/output interface, the processor, memory and input/output interface are connected with each other, wherein the input is defeated
For outgoing interface for input or output data, the memory is used to store the dress for generating medical record quality inspection report based on data processing
The application code for executing the above method is set, the processor is configured for the method for executing above-mentioned first aspect.
Fourth aspect provides a kind of computer storage medium, and the computer storage medium is stored with computer program, institute
Stating computer program includes program instruction, and described program instruction makes the processor execute above-mentioned first when being executed by a processor
The method of aspect.
In the embodiment of the present invention, pass through the geographic area pair according to belonging to all data of the medical record to quality inspection and the medical record
The quality inspection rule answered carries out quality assessment to the medical record, realizes and is detected automatically by area to medical record, improves medical record matter
The efficiency of control, meanwhile, quality inspection rule corresponding with geographic area can be adapted for the medical conditions of the geographic area, obtain quality inspection
It is more objective to report.
Detailed description of the invention
It to describe the technical solutions in the embodiments of the present invention more clearly, below will be to needed in the embodiment
Attached drawing is briefly described, it should be apparent that, drawings in the following description are only some embodiments of the invention, for ability
For the those of ordinary skill of domain, without creative efforts, it can also be obtained according to these attached drawings other attached
Figure.
Fig. 1 is that a kind of process of the method for generation medical record quality inspection report based on data processing that inventive embodiments provide is shown
It is intended to；
Fig. 2A -2E is the schematic diagram of quality inspection report provided in an embodiment of the present invention；
Fig. 3 is a kind of composition of device for generating medical record quality inspection report based on data processing provided in an embodiment of the present invention
Structural schematic diagram
Fig. 4 is the group of another device for generating medical record quality inspection report based on data processing provided in an embodiment of the present invention
At structural schematic diagram.
Specific embodiment
Following will be combined with the drawings in the embodiments of the present invention, and technical solution in the embodiment of the present invention carries out clear, complete
Site preparation description, it is clear that the described embodiment is only a part of the embodiment of the present invention, instead of all the embodiments.Based on this
Embodiment in invention, every other reality obtained by those of ordinary skill in the art without making creative efforts
Example is applied, shall fall within the protection scope of the present invention.
The principle of the technical solution of the embodiment of the present invention are as follows: belonging to the information and medical record of the medical institutions according to belonging to medical record
Geographic area, using the quality inspection rule for matching or being adapted with the medical institutions and geographic area to medical record carry out quality inspection comment
It surveys, quality inspection report is reported and exported in the quality inspection for obtaining medical record, is improved the efficiency of medical record Quality Control, is adapted to medical institutions and geographic region
The quality inspection rule in domain makes the quality inspection report determined according to the quality inspection rule more objective, true.It is obtained by the technical solution
Quality inspection report can be used for performance appraisal, for example, performance appraisal of the administration of health department to medical institutions can be used for,
Alternatively, performance appraisal of the medical institutions to medical worker or medical matters department；Administration of health department can submit according to medical institutions
The quality inspections of all medical records report and determine that the medical record of medical institutions fills in specification situation, outstanding/qualified/underproof quality inspection report
The case where；The quality inspection for all medical records that medical institutions submit according to medical department or medical worker, which is reported, determines medical department or doctor
The medical record of business personnel fills in the case where specification situation, outstanding/qualification/underproof quality inspection report, etc..Pass through the technical solution
Obtain quality inspection report can also be used for medical institutions, medical department, medical worker etc. submit case history/medical record object from
I detects, medical institutions,
It is a kind of method for generating medical record quality inspection report based on data processing that inventive embodiments provide referring to Fig. 1, Fig. 1
Flow diagram, as shown, this method comprises:
S101, determines the corresponding all data of medical record to quality inspection, all data include medical institutions' information data,
Geographic information data, user basic information data, medical information data, hospital course information data and medical expense Information Number
According to.
In the embodiment of the present invention, medical institutions' information can specifically include the tissue of the title of medical institutions, medical institutions
Institution Code, optionally, medical institutions' information can also include the attribute information of medical institutions, and the attribute information is for indicating doctor
The type or grade of mechanism are treated, for example, medical institutions are second-grade hospital, is then to the corresponding medical institutions' information of the medical record of quality inspection
Second level.Geographic information data can specifically include the data, for example, Beijing such as province, city, county, area for indicating administrative region
City, Hebei province, etc.；Geographic information data also may include the number with some area for the whole part range for indicating this area
According to, such as southwestern section of China, southeast section of northeast province, etc..
User basic information data, medical information data, hospital course information data and medical expense information data are equal
The data in the medical record of quality inspection are waited for for this.Wherein, user basic information data include that birth weight data, newborn enter
The corresponding data of institute's weight data, patient's identification number, the corresponding data of gender, date of birth data, age data, medical payment method
What is recorded in the medical records such as data, health card number is used to indicate the basic data of the corresponding illness user of the medical record；Diagnosis and treatment
Information data includes being recorded in the medical records such as admission time data, discharge time data, practical length of stay for feeding back this
The data for the information that illness user generates in hospital course；Medical information data include Main Diagnosis data, Main Diagnosis volume
What is recorded in the medical records such as code data, other diagnostic datas, other diagnosis coding data is used to feed back medical worker to the illness
The relevant information data of the diagnosis of user；Medical expense information data includes total cost information data, treatment category information data, consumption
Recorded in the medical records such as material category information data for feed back illness user carry out it is generated each during Medical treatment
Item cost data.
In the embodiment of the present invention, can there is following two mode to determine the corresponding all data of medical record to quality inspection:
First way can should be drawn to the data in the medical record of quality inspection by quality inspection user/medical institutions/medical worker
Point, sort out form tables of data, in the tables of data comprising to quality inspection medical record corresponding all data, then can be from the tables of data
Middle reading data, so that it is determined that being somebody's turn to do the corresponding all data of medical record to quality inspection.
The second way, user do not wait for that the data in the medical record of quality inspection carry out classified finishing and form tables of data to this, then may be used
Content in medical record to quality inspection is got to wait for that this, medical record of quality inspection carries out content recognition, in the medical record that then will acquire
Content matched with preset content, so that it is determined that the content in the medical record that will acquire is divided to obtain the medical record
User basic information data, medical information data, hospital course information data and medical expense information data, finally obtain
The medical institutions' information data and geographic information data of user's input, to obtain the corresponding medical institutions' information of medical record to quality inspection
Data and geographic information data.
For example, waiting for that the medical record of quality inspection carries out the content that content recognition is got to this is male 2. female of name king XX gender 11.
Date of birth, then preset content is " name ", " gender ", " 1. male 2. female's dates of birth ", wherein " name " corresponding project
Entitled " name ", " gender " corresponding project name are " gender ", and " 1. male 2. female's dates of birth ", matched project name was
" date of birth ", the then content in medical record that will acquire are matched with preset content, due to the content difference got
With preset content " name ", " gender " and " 1. male 2. female's dates of birth " matching, it is determined that between " name " and " gender "
Content " king XX " be the corresponding data of " name " matched project name " name ", determine " gender " and " 1. male 2. female be born
Content " 1 " between date " is the corresponding data of " gender " matched project name " gender ".
S102 determines the corresponding quality inspection of the medical record according to medical institutions' information data and the geographic information data
Rule, the quality inspection rule include the corresponding quality inspection rule of user basic information, the corresponding quality inspection rule of medical information, were hospitalized
At least one of the corresponding quality inspection rule of journey information and the corresponding quality inspection rule of medical expense information quality inspection rule.
Here it is possible to whole quality inspection rules is stored in quality inspection rule database in advance, then respectively from the quality inspection
It is the quality inspection rule work of different medical institutions' information data and geographic information data selected section or whole in rule database
For its corresponding quality inspection rule, the quality inspection rule and medical institutions' information data and geography information number that the selection obtains then are saved
According to corresponding relationship.
It in one possible implementation, can be by quality inspection rule that the selection obtains in quality inspection rule database
Number is stored in quality inspection rule file, and saves the disease quality inspection rule file and medical institutions' information data and geography information number
Corresponding relationship between.It, can be according to case quality inspection rule file and therapeutic machine when determining the corresponding quality inspection rule of medical record
Corresponding relationship between structure information data and geographic information data determines matter corresponding with medical institutions' information and geography information
Rule file is examined, is then obtained from quality inspection rule database according to the number saved in the quality inspection rule file and accordingly to be numbered
Quality inspection rule, to obtain quality inspection rule corresponding with the medical record.
In alternatively possible implementation, the quality inspection rule that selection can also be obtained is from quality inspection rule database
It obtains, and saves into quality inspection rule file, and save the quality inspection rule file and medical institutions' information and geographic information data
Between corresponding relationship.It, can be according to case quality inspection rule file and medical institutions when determining the corresponding quality inspection rule of medical record
Corresponding relationship between information data and geographic information data determines quality inspection corresponding with medical institutions' information and geography information
Then rule file obtains quality inspection rule corresponding with the medical record from the quality inspection rule file.
In the specific implementation, the name/identity etc. of the quality inspection rule file can be used to uniquely indicate quality inspection rule
The data and medical institutions' information data and geographic information data of file are stored in a tables of data, to save quality inspection rule text
Corresponding relationship between part and medical institutions' information data and geographic information data.
Illustratively, the corresponding relationship between quality inspection rule file and medical institutions' information data and geographic information data can
With as shown in table 1.
| Quality inspection rule file mark | Medical institutions' information data | Geographic information data |
| Quality inspection rule file mark 1 | Medical institutions' information data 1 | Geographic information data 1 |
| Quality inspection rule file mark 2 | Medical institutions' information data 2 | Geographic information data 2 |
| … | … | … |
Table 1
In the embodiment of the present invention, the whole quality inspection rules saved in quality inspection rule database may include specifically that user is basic
The corresponding quality inspection rule of information, the corresponding quality inspection rule of medical information, the corresponding quality inspection rule of hospital course information and payment for medical care
With the corresponding quality inspection rule of information.
Wherein, the corresponding quality inspection rule of essential information can be as shown in table 2:
Table 2
The corresponding quality inspection rule of hospital course information can be as shown in table 3:
Table 3
The corresponding quality inspection rule of medical information can be as shown in table 4:
Table 4
The corresponding quality inspection rule of medical expense information can be as shown in table 5:
| Project name | Report item title | Deduction of points |
| Total cost | Total cost is empty mistake | 4 |
| Total cost | Total cost≤0 mistake | 2 |
| Total cost | Total cost is not equal to the sum of subitem mistake | 2 |
| Total cost | Total cost=other charging errors | 2 |
Table 5
In the specific implementation, can the geographic region according to belonging to the property of the medical institutions belonging to medical record, grade, medical institutions
The quality inspection rule of selected section or whole from the quality inspection rule in table 2- table 5 such as domain is regular as its corresponding quality inspection.
S103, according to the quality inspection rule, and, the user basic information data, medical information data, hospital course
Information data and medical expense information data carry out quality assessment to the medical record, obtain the quality inspection report of the medical record.
Quality inspection report may include the mass fraction of the corresponding each quality inspection project of quality inspection rule and the matter of the medical record
Gross score is measured, at this point, according to quality inspection rule and user basic information data, medical information data, hospital course information data
The concrete mode for carrying out quality assessment to medical record with medical expense information data can be with are as follows: determines that quality inspection rule is corresponding each
Quality inspection project, from user basic information data, medical information data, hospital course information data and medical expense information data
The corresponding data of the middle each quality inspection project of determination；According to the corresponding quality inspection rule of each quality inspection project and each quality inspection project pair
The data answered respectively score to each quality inspection project, obtain the mass fraction of each quality inspection project；By each quality inspection project
The sum of mass fraction be determined as the quality gross score of medical record.
For example, the quality inspection rule of the medical record is the corresponding quality inspection rule of essential information shown in above-mentioned table 2, then can determine
It is that birth weight, newborn are admitted to hospital entry name shown in the tables such as weight, patient's identification number 1 that the quality inspection rule, which corresponds to quality inspection project,
Claim project shown in column, then can obtain birth weight, newborn from user basic information data respectively and be admitted to hospital body
The corresponding data of weight project, judge whether these data meet condition of deducting points shown in table 2, if satisfied, then deducting corresponding scores
Afterwards, the score further according to the item score and deduction determines the mass fraction of each quality inspection project；It is somebody's turn to do if not satisfied, then determining
The mass fraction of project is its corresponding item score.Such as, project is specially birth weight, if believed substantially from user
The corresponding data of birth weight have not been obtained in breath data, it is determined that 4 points of button determines the quality inspection of birth weight
Score is 4-4=0 points；It is incorrect if there is the weight digit of the corresponding data of neonatal weight and the data, it is determined that button 2
Point, determine the quality inspection score of birth weight for 4-2=2 points；If there is the corresponding data of neonatal weight and the number
According to weight digit it is correct, it is determined that the quality inspection score of birth weight be 4 points.
Illustratively, the content of quality inspection report can be as shown in Figure 2 A, and it is right to contain quality inspection rule in quality inspection report
The quality gross score of each quality inspection project answered, the mass fraction of each quality inspection project and quality inspection report.
S104 exports the quality inspection report.
Here it is possible to quality inspection report be exported in the form of report or chart, for example, content such as Fig. 2A of quality inspection report
It is shown, then the mass fraction of each project can be presented in a manner of table, it specifically can be as shown in Figure 2 B.
In the embodiment of the present invention, by can determine ground belonging to the medical record according to the corresponding all data of the medical record to quality inspection
Region is managed, the quality inspection rule that then selection is adapted to the geographic area carries out quality assessment to the case history and obtains the quality inspection of the medical record
Report exports quality inspection report, realizes the automatic judgment to medical record quality, improve the efficiency of medical record Quality Control；In addition, being used for
The quality inspection rule and geographic area belonging to medical record for carrying out quality assessment are adapted, and realize the differentiation processing of quality inspection rule,
So that quality inspection rule can adapt to the specific medical conditions of the geographic area.
Optionally, above-mentioned quality inspection report can also include the credit rating of medical record, basic according to quality inspection rule and user
Information data, medical information data, hospital course information data and medical expense information data carry out quality assessment to medical record
Concrete mode can be with are as follows: determines the corresponding full marks threshold value of quality inspection rule and credit rating score threshold, the credit rating point
Number threshold value includes the first score threshold and the second score threshold, and the first score threshold is greater than the second score threshold；If medical record
Quality gross score be full marks threshold value, it is determined that the credit rating of the medical record be it is outstanding, if the quality gross score of the medical record is not
Full marks threshold value, it is determined that the quality inspection deduction of points project of medical record；If the quality gross score of medical record is greater than or equal to the first score threshold,
And quality inspection deduct points project be not the first quality inspection project, it is determined that the credit rating of medical record be it is outstanding, the first quality inspection project be symbol
Close the quality inspection project of A intermediate item in international medical record standards of grading；If the quality gross score of medical record is simultaneously less than the first score threshold
And it is greater than or equal to the second score threshold, also, quality inspection deduction of points project is not the first quality inspection project, it is determined that the quality etc. of medical record
Grade is qualification；If the quality gross score of medical record is the first quality inspection project less than the second score threshold or quality inspection deduction of points project,
Determine that the credit rating of medical record is unqualified.
Here, full marks threshold value is the sum of the item score of the corresponding each quality inspection project of quality inspection rule, the first score threshold
Value and the second score threshold are two scores for being less than full marks threshold value.For example, full marks threshold value is 100 points, then the first score threshold
It can be set to 80,90, equivalence；Second score threshold can be set to 60,70 equivalences.
Quality inspection deduction of points project is that mass fraction is not its corresponding project in the corresponding each quality inspection project of quality inspection rule
The quality inspection project of score.For example, quality inspection project is birth weight, the item score of birth weight is 4 points, newly
The mass fraction of raw youngster's birth weight is 2 points, it is determined that birth weight is quality inspection deduction of points project.
Meet A intermediate item in international medical record standards of grading quality inspection project include newborn be admitted to hospital weight, newborn birth
Weight, from school's formula and total cost.
Citing is to be illustrated, for example, the corresponding full marks threshold value of quality inspection rule is 100, the first score threshold is 95, second
Score threshold is 90, if the quality gross score of the medical record be more than or equal to 95 and, quality inspection deduction of points project do not enter for newborn
Institute's weight, birth weight, from one of school's formula and total cost, it is determined that the credit rating of the medical record be it is outstanding；
If the quality gross score of the medical record be 90-94 and, quality inspection deduction of points project is not that be admitted to hospital weight, newborn of newborn goes out raw body
Again, from one of school's formula and total cost, it is determined that the credit rating of the medical record is qualification；If the quality total score of the medical record
Number for 90 hereinafter, alternatively, quality inspection deduct points project be not newborn be admitted to hospital weight, birth weight, from school's formula and total expense
One of with, it is determined that the credit rating of the medical record is unqualified.
Illustratively, the content of quality inspection report can be as shown in Figure 2 C, in addition to including shown in Fig. 2A in quality inspection report
Outside content, the credit rating of medical record is further comprised.
Judged by quality gross score to medical record and quality inspection project of deducting points, the credit rating to medical record may be implemented
Automatic judgement；By exporting the credit rating of medical record in quality inspection report, the quality etc. that family understands the medical record can be used
Grade, and then the specification feelings that medical worker related with the medical record or medical institutions' case history fill in can be determined according to the credit rating
Condition.
Optionally, above-mentioned quality inspection report can also include the type of error of quality inspection deduction of points project；According to quality inspection rule and
User basic information data, medical information data, hospital course information data and medical expense information data carry out matter to medical record
The concrete mode for measuring evaluation and test can be with are as follows: if quality inspection deduction of points project is the second quality inspection project, it is determined that quality inspection is deducted points project
Type of error is logicality mistake, and the second quality inspection project is the quality inspection project do not filled in medical record, also, user basic information number
According to, exist in medical information data, hospital course information data and medical expense information data and the second quality inspection item association
Project or the corresponding data of item；If quality inspection is deducted points, project is not the second quality inspection project, it is determined that the mistake of quality inspection deduction of points project
Accidentally type is completeness error.
Here, the second quality inspection project is that it should fill in but not fill in or fill in the quality inspection project of mistake.Specifically may be used
First determine that the corresponding data of quality inspection deduction of points project whether there is, and if it exists, then determine that quality inspection deduction of points project is not the second matter
Inspection project；If it does not exist, it is determined that whether there is with the project or item of quality inspection deduction of points item association, and if it exists, then determine
The quality inspection deducts points project for the second quality inspection project, if it does not exist, it is determined that quality inspection deduction of points project is not the second quality inspection deduction of points item
Mesh.For example, the quality inspection is deducted points, project is other diagnosis, diagnoses associated other diagnosis coding of quality inspection project with other, if its
The corresponding data of his diagnosis coding exist and the data of other diagnosis are not present, it is determined that other are diagnosed as the second quality inspection item
Mesh.
The concrete condition of second quality inspection project can be as shown in table 6.
| Other diagnosis | Other diagnosis have coding without title |
| Chief surgical or action name | Chief surgical title has expense not fill in |
| Chief surgical or operation coding | Chief surgical coding has expense not fill in |
| Other operations or operation coding | Other Operation encodings are not filled out when there is operation names |
| Operation and date of operation | Date of surgery is not filled out when there is operation names |
| Operation and date of operation | Date of surgery is not within the hospital stay time |
| Wound healing grade | Notch grade is not filled in when performing the operation class coding |
| Operation rank | Operation rank is not filled in when operating room encodes |
| Patient | Patient does not fill in when there is operating room coding |
| Pathological diagnosis coding | Pathological diagnosis coding is not filled in when there is expense |
| Pathological diagnosis | Pathological diagnosis is not filled in when there is expense |
| Pathological number | Pathological number is not filled in when there is expense |
| The external cause of Injuries and poisoning | Injuries and poisoning reason is not filled out in main diagnosis S or T |
| Injuries and poisoning external cause coding | Injuries and poisoning coding is not filled in when having reason |
| Injuries and poisoning external cause coding | When Injuries and poisoning coding has reason not between VY |
| Blood group | Blood is time-consuming not to be filled in blood group having |
| Blood group | Blood group the mistakes such as does not look into there is blood time-consuming fill in |
| Rh blood group | Blood is time-consuming not to be filled in Rh blood group having |
| Rh blood group | Rh blood group the mistakes such as does not look into there is blood time-consuming fill in |
| Total cost | Total cost is empty mistake |
| Total cost | Total cost≤0 mistake |
| Total cost | Total cost is not equal to the sum of subitem mistake |
| Total cost | Total cost=other charging errors |
Table 6
Optionally, report that quality inspection report can also include the matter there are in the case where quality inspection deduction of points project in the quality inspection
The deduction of points content of deduction of points project is examined, i.e., particularly due to deduction of points caused by what problem.For example, quality inspection deduction of points project is newborn
Birth weight, the content of deduction of points are production twins birth weight digit mistake, then in addition to including newborn in quality inspection report
It outside the mass fraction and type of error of birth weight, may also include " production twins birth weight digit mistake " this content.
Illustratively, the content of quality inspection report can be as shown in Figure 2 D, in addition to including shown in fig. 2 C in quality inspection report
Outside content, the type of error and deduction of points content of quality inspection deduction of points project are further comprised.
Optionally, it reports in the quality inspection there are in the case where quality inspection deduction of points project, it, can be with when exporting quality inspection report
It is deducted points project and quality inspection deduction of points project in a manner of be different from other quality inspection projects in quality inspection report to the quality inspection
Related content is (such as the mass fraction of quality inspection deduction of points project, the type of error of quality inspection deduction of points project, quality inspection deduction of points project
Deduction of points content etc.) be marked after, export and the quality inspection after being marked reported.
For example, the content of quality inspection report is as shown in Figure 2 D, then the quality inspection report after being marked can be as shown in Figure 2 D.
It is not the quality inspection project of its corresponding full marks threshold value by mark quality score prominent in quality inspection is reported, so that with
Family, which can quickly navigate to, fills in nonstandard quality inspection project.
The method of inventive embodiments is described above, the device of inventive embodiments is described below.
It is a kind of dress for generating medical record quality inspection report based on data processing provided in an embodiment of the present invention referring to Fig. 3, Fig. 3
The composed structure schematic diagram set, the device 30 include:
Data determining module 301, for determining that the corresponding all data of medical record to quality inspection, all data include doctor
Treat organization information data, geographic information data, user basic information data, medical information data, hospital course information data with
And medical expense information data；
Quality inspection rule determining module 302, for true according to medical institutions' information data and the geographic information data
Determine the corresponding quality inspection rule of the medical record, the quality inspection rule includes the corresponding quality inspection rule of user basic information, medical information
In the corresponding quality inspection rule of corresponding quality inspection rule, hospital course information quality inspection rule corresponding with medical expense information at least
A kind of quality inspection rule；
It reports determining module 303, is used for according to the quality inspection rule, and, the user basic information data, diagnosis and treatment letter
It ceases data, hospital course information data and medical expense information data and quality assessment is carried out to the medical record, obtain the medical record
Quality inspection report；
Report output module 304, for exporting the quality inspection report.
In a kind of possible design, the quality inspection report includes the matter of the corresponding each quality inspection project of the quality inspection rule
Measure the quality gross score of score and the medical record；
The report determining module 303 is specifically used for:
Determine the corresponding each quality inspection project of quality inspection rule, and from the user basic information data, medical information
The corresponding data of each quality inspection project are determined in data, hospital course information data and medical expense information data；
According to each corresponding quality inspection rule of quality inspection project and the corresponding data of each quality inspection project respectively to institute
It states each quality inspection project to score, obtains the mass fraction of each quality inspection project；
The sum of the mass fraction of each quality inspection project is determined as to the quality gross score of the medical record.
In a kind of possible design, the quality inspection report further includes the credit rating of the medical record；
The report determining module 303 is specifically used for:
Determine the corresponding full marks threshold value of the quality inspection rule and credit rating score threshold, the credit rating score threshold
Including the first score threshold and the second score threshold, first score threshold is greater than second score threshold；
If the quality gross score is the full marks threshold value, it is determined that the credit rating of the medical record is outstanding；
If the quality gross score is not the full marks threshold value, it is determined that the quality inspection deduction of points project of the medical record；
If the quality gross score is greater than or equal to first score threshold, and quality inspection deduction of points project is not
First quality inspection project, it is determined that the credit rating of the medical record be it is outstanding, the first quality inspection project is to meet international medical record and comment
The quality inspection project of A intermediate item in minute mark standard；
If the quality gross score is less than the first score threshold and is greater than or equal to second score threshold, and
And the quality inspection deduction of points project is not the first quality inspection project, it is determined that the credit rating of the medical record is qualification；
If it is first matter that the quality gross score, which is less than second score threshold or quality inspection deduction of points project,
Inspection project, it is determined that the credit rating of the medical record is unqualified.
In a kind of possible design, the quality inspection report further includes the type of error of quality inspection deduction of points project；
The report determining module 303 is specifically used for:
If quality inspection deduction of points project is the second quality inspection project, it is determined that the type of error of the quality inspection deduction of points project is
Logicality mistake, the second quality inspection project are the quality inspection project do not filled in the medical record, also, the user basic information
Exist and the second quality inspection project in data, medical information data, hospital course information data and medical expense information data
Associated project or the corresponding data of item；
If the quality inspection deduction of points project is not the second quality inspection project, it is determined that the mistake of the quality inspection deduction of points project
Type is completeness error.
In a kind of possible design, the report output module 304 is specifically used for:
Quality inspection deduction of points project is marked in a manner of being different from other quality inspection projects in quality inspection report,
Other described quality inspection projects are to remove except the quality inspection deduction of points project in the corresponding each quality inspection project of the quality inspection rule
Quality inspection project；
The quality inspection that quality inspection deduction of points project is marked is exported to report.
In a kind of possible design, the report output module 304 is specifically used for:
The quality inspection report is exported in the form of report or chart.
It should be noted that unmentioned content can be found in the description of embodiment of the method in the corresponding embodiment of Fig. 3, here
It repeats no more.
In the embodiment of the present invention, the device for generating medical record quality inspection report based on data processing passes through according to the disease to quality inspection
The corresponding all data of case can determine geographic area belonging to the medical record, and then selection is adapted to the quality inspection rule of the geographic area
Quality assessment is carried out to the case history and obtains the quality inspection report of the medical record, exports quality inspection report, realize to medical record quality from
Dynamic evaluation and test, improves the efficiency of medical record Quality Control；In addition, the quality inspection rule for carrying out quality assessment and geographic region belonging to medical record
Domain is adapted, and the differentiation processing of quality inspection rule is realized, so that quality inspection rule can adapt to the specific medical treatment of the geographic area
Situation.
Referring to fig. 4, Fig. 4 is that another generation medical record quality inspection based on data processing provided in an embodiment of the present invention is reported
The composed structure schematic diagram of device, the device 40 include processor 401, memory 402 and input/output interface 403.Processing
Device 401 is connected to memory 402 and input/output interface 403, such as processor 401 can be connected to memory by bus
402 and input/output interface 403.
Processor 401 is configured as that the device of the generation medical record quality inspection report based on data processing is supported to execute Fig. 1
Corresponding function in the method for generating medical record quality inspection report based on data processing.The processor 401 can be center
Processor (central processing unit, CPU), network processing unit (network processor, NP), hardware chip
Or any combination thereof.Above-mentioned hardware chip can be specific integrated circuit (application specific integrated
Circuit, ASIC), programmable logic device (programmable logic device, PLD) or combinations thereof.Above-mentioned PLD can
To be Complex Programmable Logic Devices (complex programmable logic device, CPLD), field programmable logic
Gate array (field-programmable gate array, FPGA), Universal Array Logic (generic array logic,
GAL) or any combination thereof.
402 memory of memory is for storing program code etc..Memory 402 may include volatile memory
(volatile memory, VM), such as random access memory (random access memory, RAM)；Memory 402
It may include nonvolatile memory (non-volatile memory, NVM), such as read-only memory (read-only
Memory, ROM), flash memory (flash memory), hard disk (hard disk drive, HDD) or solid state hard disk
(solid-state drive, SSD)；Memory 402 can also include the combination of the memory of mentioned kind.
The input/output interface 403 is for input or output data.
Processor 401 can call said program code to execute following operation:
Determine the corresponding all data of medical record to quality inspection, all data includes medical institutions' information data, geography
Information data, user basic information data, medical information data, hospital course information data and medical expense information data；
The corresponding quality inspection rule of the medical record is determined according to medical institutions' information data and the geographic information data,
The quality inspection rule includes the corresponding quality inspection rule of user basic information, the corresponding quality inspection rule of medical information, hospital course letter
Cease at least one of corresponding quality inspection rule and the corresponding quality inspection rule of medical expense information quality inspection rule；
According to the quality inspection rule, and, the user basic information data, medical information data, hospital course information
Data and medical expense information data carry out quality assessment to the medical record, obtain the quality inspection report of the medical record；
The quality inspection report is exported by input/output interface 403.
It should be noted that the realization of each operation can also correspond to the corresponding description of above method embodiment；The place
Other operations executed in above method embodiment can also be cooperated with input/output interface 403 by managing device 401.
The embodiment of the present invention also provides a kind of computer storage medium, and the computer storage medium is stored with computer journey
Sequence, the computer program include program instruction, and described program instruction executes the computer such as
Method described in previous embodiment, the computer can be the generation medical record quality inspection report mentioned above based on data processing
Device a part.For example, above-mentioned processor 401.
Those of ordinary skill in the art will appreciate that realizing all or part of the process in above-described embodiment method, being can be with
Relevant hardware is instructed to complete by computer program, the program can be stored in a computer-readable storage medium
In, the program is when being executed, it may include such as the process of the embodiment of above-mentioned each method.Wherein, the storage medium can be magnetic
Dish, CD, ROM or RAM etc..
The above disclosure is only the preferred embodiments of the present invention, cannot limit the right model of the present invention with this certainly
It encloses, therefore equivalent changes made in accordance with the claims of the present invention, is still within the scope of the present invention.
Claims (10)
1. a kind of method for generating medical record quality inspection report based on data processing characterized by comprising
Determine the corresponding all data of medical record to quality inspection, all data includes medical institutions' information data, geography information
Data, user basic information data, medical information data, hospital course information data and medical expense information data；
The corresponding quality inspection rule of the medical record is determined according to medical institutions' information data and the geographic information data, it is described
Quality inspection rule includes the corresponding quality inspection rule of user basic information, the corresponding quality inspection rule of medical information, hospital course information pair
At least one of the corresponding quality inspection rule of quality inspection rule and medical expense information answered quality inspection rule；
According to the quality inspection rule, and, the user basic information data, medical information data, hospital course information data
Quality assessment is carried out to the medical record with medical expense information data, obtains the quality inspection report of the medical record；
Export the quality inspection report.
2. the method according to claim 1, wherein quality inspection report includes that the quality inspection rule is corresponding each
The mass fraction of a quality inspection project and the quality gross score of the medical record；
It is described regular according to the quality inspection, and, the user basic information data, medical information data, hospital course information
Data and medical expense information data carry out quality assessment to the medical record, obtain the quality inspection report of the medical record, comprising:
Determine the corresponding each quality inspection project of quality inspection rule, and from the user basic information data, medical information data,
The corresponding data of each quality inspection project are determined in hospital course information data and medical expense information data；
According to each corresponding quality inspection rule of quality inspection project and the corresponding data of each quality inspection project respectively to described each
A quality inspection project scores, and obtains the mass fraction of each quality inspection project；
The sum of the mass fraction of each quality inspection project is determined as to the quality gross score of the medical record.
3. according to the method described in claim 2, it is characterized in that, quality inspection report further includes the quality etc. of the medical record
Grade；
It is described regular according to the quality inspection, and, the user basic information data, medical information data, hospital course information
Data and medical expense information data carry out quality assessment to the medical record, obtain the quality inspection report of the medical record, further includes:
It determines the corresponding full marks threshold value of the quality inspection rule and credit rating score threshold, the credit rating score threshold includes
First score threshold and the second score threshold, first score threshold are greater than second score threshold；
If the quality gross score is the full marks threshold value, it is determined that the credit rating of the medical record is outstanding；
If the quality gross score is not the full marks threshold value, it is determined that the quality inspection deduction of points project of the medical record；
If the quality gross score is greater than or equal to first score threshold, and quality inspection deduction of points project is not first
Quality inspection project, it is determined that the credit rating of the medical record be it is outstanding, the first quality inspection project is to meet international medical record scoring mark
The quality inspection project of A intermediate item in standard；
If the quality gross score is less than the first score threshold and is greater than or equal to second score threshold, also, institute
Stating quality inspection deduction of points project is not the first quality inspection project, it is determined that the credit rating of the medical record is qualification；
If it is the first quality inspection item that the quality gross score, which is less than second score threshold or quality inspection deduction of points project,
Mesh, it is determined that the credit rating of the medical record is unqualified.
4. according to the method described in claim 3, it is characterized in that, quality inspection report further includes the quality inspection deduction of points project
Type of error；
It is described regular according to the quality inspection, and, the user basic information data, medical information data, hospital course information
Data and medical expense information data carry out quality assessment to the medical record, obtain the quality inspection report of the medical record, further includes:
If the quality inspection deduction of points project is the second quality inspection project, it is determined that the type of error of the quality inspection deduction of points project is logic
Property mistake, the second quality inspection project is the quality inspection project do not filled in the medical record, also, the user basic information number
According to, exist in medical information data, hospital course information data and medical expense information data and the second quality inspection project is closed
The corresponding data of quality inspection project or item of connection；
If the quality inspection deduction of points project is not the second quality inspection project, it is determined that the type of error of the quality inspection deduction of points project
For completeness error.
5. the method according to claim 3 or 4, which is characterized in that the output quality inspection report, comprising:
Quality inspection deduction of points project is marked in a manner of being different from other quality inspection projects in quality inspection report, it is described
Other quality inspection projects are the quality inspection removed except the quality inspection deduction of points project in the corresponding each quality inspection project of the quality inspection rule
Project；
The quality inspection that quality inspection deduction of points project is marked is exported to report.
6. method according to claim 1-4, which is characterized in that the output quality inspection, which is reported, includes:
The quality inspection report is exported in the form of report or chart.
7. a kind of device for generating medical record quality inspection report based on data processing characterized by comprising
Data determining module, for determining the corresponding all data of medical record to quality inspection, all data includes medical institutions
Information data, geographic information data, user basic information data, medical information data, hospital course information data and medical treatment
Cost information data；
Quality inspection rule determining module, for determining the disease according to medical institutions' information data and the geographic information data
The corresponding quality inspection rule of case, the quality inspection rule include the corresponding quality inspection rule of user basic information, the corresponding matter of medical information
The quality inspection of at least one of the corresponding quality inspection rule of inspection rule, hospital course information quality inspection rule corresponding with medical expense information
Rule；
Report determining module, for according to quality inspection rule, and, the user basic information data, medical information data,
Hospital course information data and medical expense information data carry out quality assessment to the medical record, obtain the quality inspection report of the medical record
It accuses；
Report output module, for exporting the quality inspection report.
8. device according to claim 7, which is characterized in that the quality inspection report includes that the quality inspection rule is corresponding each
The mass fraction of a quality inspection project and the quality gross score of the medical record；
The report determining module is specifically used for:
Determine the corresponding each quality inspection project of quality inspection rule, and from the user basic information data, medical information data,
The corresponding data of each quality inspection project are determined in hospital course information data and medical expense information data；
According to each corresponding quality inspection rule of quality inspection project and the corresponding data of each quality inspection project respectively to described each
A quality inspection project scores, and obtains the mass fraction of each quality inspection project；
The sum of the mass fraction of each quality inspection project is determined as to the quality gross score of the medical record.
9. a kind of device for generating medical record quality inspection report based on data processing, including processor, memory and input and output
Interface, the processor, memory and input/output interface are connected with each other, wherein the input/output interface for inputting or
Output data, the memory execute such as right for calling said program code for storing program code, the processor
It is required that the described in any item methods of 1-6.
10. a kind of computer storage medium, which is characterized in that the computer storage medium is stored with computer program, described
Computer program includes program instruction, and described program instruction makes the processor execute such as claim when being executed by a processor
The described in any item methods of 1-6.
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