CN109887558A - A kind of patient medical history quality control system - Google Patents
A kind of patient medical history quality control system Download PDFInfo
- Publication number
- CN109887558A CN109887558A CN201811642364.4A CN201811642364A CN109887558A CN 109887558 A CN109887558 A CN 109887558A CN 201811642364 A CN201811642364 A CN 201811642364A CN 109887558 A CN109887558 A CN 109887558A
- Authority
- CN
- China
- Prior art keywords
- quality control
- electronic health
- content
- health record
- case history
- Prior art date
- Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
- Pending
Links
- 238000003908 quality control method Methods 0.000 title claims abstract description 82
- 238000012360 testing method Methods 0.000 claims abstract description 21
- 238000001514 detection method Methods 0.000 claims abstract description 18
- 201000010099 disease Diseases 0.000 claims description 7
- 208000037265 diseases, disorders, signs and symptoms Diseases 0.000 claims description 7
- PEDCQBHIVMGVHV-UHFFFAOYSA-N Glycerine Chemical compound OCC(O)CO PEDCQBHIVMGVHV-UHFFFAOYSA-N 0.000 claims description 3
- 235000013399 edible fruits Nutrition 0.000 claims 1
- 238000007689 inspection Methods 0.000 claims 1
- 230000009286 beneficial effect Effects 0.000 abstract description 2
- 238000005516 engineering process Methods 0.000 abstract description 2
- 238000000034 method Methods 0.000 description 5
- 230000003542 behavioural effect Effects 0.000 description 4
- 238000011156 evaluation Methods 0.000 description 3
- 230000007812 deficiency Effects 0.000 description 2
- 238000012986 modification Methods 0.000 description 2
- 230000004048 modification Effects 0.000 description 2
- 238000012549 training Methods 0.000 description 2
- 238000006243 chemical reaction Methods 0.000 description 1
- 238000012217 deletion Methods 0.000 description 1
- 230000037430 deletion Effects 0.000 description 1
- 238000010586 diagram Methods 0.000 description 1
- 238000005303 weighing Methods 0.000 description 1
Landscapes
- Medical Treatment And Welfare Office Work (AREA)
Abstract
The present invention provides a kind of patient medical history quality control system, belongs to the field of medical instrument technology, carries out Quality Control to the electronic health record that doctor makes to obtain Quality Control report for being supplied to school；It include: database, for storing multiple electronic health records and Quality Control strategy, each electronic health record includes the case history content of multiple element entries and corresponding each element entry, and case history content is made of the sub- content for corresponding to multiple interrogation points；Quality Control module, connect database, for obtaining electronic health record and Quality Control strategy from database, and element entry is carried out to each element entry in electronic health record according to Quality Control strategy and detects to obtain element entry testing result, and content detection is carried out to each case history content and obtains content detection as a result, and generating Quality Control report according to element entry testing result and content detection result.Beneficial effects of the present invention: hospital can carry out Quality Control operation after case history completes, to improve the accuracy of electronic health record.
Description
Technical field
The present invention relates to the field of medical instrument technology more particularly to a kind of patient medical history quality control systems.
Background technique
The deficiency of traditional outpatient service hand written case histories: careless handwriting, without storage can not inquire, without supervision can not Quality Control, data without
Method is shared, and therefore, hand-written patient medical history is easy to cause medical tangle, and there are management blind areas.
The deficiency of current clinic electronic medical recorder: selective type operation/text input has leakage to select content and wrong word more, is not allowed
Really, Quality Control link is lacked after case history completes.
Summary of the invention
Aiming at the problems existing in the prior art, the present invention relates to a kind of patient medical history quality control systems.
The present invention adopts the following technical scheme:
A kind of patient medical history quality control system carries out Quality Control to the electronic health record that doctor makes for being supplied to school to obtain
Quality Control report；Include:
Database, for storing multiple electronic health records and Quality Control strategy, each electronic health record includes multiple element entries
With the case history content of each element entry of correspondence, the case history content is made of the sub- content for corresponding to multiple interrogation points；
Quality Control module connects the database, for obtaining the electronic health record and the Quality Control plan from the database
Slightly, and element entry is carried out to each of the electronic health record element entry according to the Quality Control strategy respectively and detects to obtain member
Prime implicant testing result, and in being carried out respectively to each of the electronic health record case history content according to the Quality Control strategy
Hold detection and obtains content detection as a result, and generating the Quality Control according to the element entry testing result and the content detection result
Report.
Preferably, the school includes multiple departments, and each department includes multiple doctors.
Preferably, the element entry detection includes judging whether the element entry in the electronic health record meets present count
Amount and default type simultaneously obtain the element entry testing result.Preferably, judging the element entry in the electronic health record is
It is no to meet preset quantity and default type and obtain the element entry testing result.
Preferably, the database is also used to store the first ratio with the doctor with the every other doctor of department
To case history；
The quality Control module, which is also used to obtain from the database, has identical examine with the electronic health record of the doctor
Described the first of disconnected result compares case history, and the electronic health record and described first are compared case history and carry out content comparison, with
To the first comparing result；
The Quality Control report includes first comparison result.
Preferably, the database is also used to store identical with the disease of the electronic health record second and compares case history；
The quality Control module, which is also used to obtain from the database, compares case history with described second, and by the electronic health record
Case history is compared with described second and carries out content comparison, to obtain the second comparing result；
The Quality Control report includes second comparison result.
Preferably, the quality Control module generates the matter according to the element entry testing result and the content detection result
Control report includes the scores of medical records for generating the corresponding element entry testing result.
Preferably, the quality Control module also provides for checking the electronics disease using day, the moon as the period respectively to hospital side
The scores of medical records gone through.
Beneficial effects of the present invention: after the completion of electronics patient medical history, system can provide evaluation to this medical record writing process,
Efficient including doctor's interrogation, case history completes quality etc.；
By behavioural analysis and feedback, feedback training is carried out to the behavioural habits of doctor, and then specification doctor sees a doctor behavior,
Reinforce interrogation precision and efficiency, improves the standard rate of medical record writing；
Patient medical history Quality Control department is supported to carry out quality control to full Out-patient Department case history simultaneously, to patient medical history performance
It gives and objectively evaluates, data foundation is provided to patient medical history specification writing.
Detailed description of the invention
Fig. 1 is the functional block diagram of patient medical history quality control system in a preferred embodiment of the present invention.
Specific embodiment
It should be noted that in the absence of conflict, following technical proposals be can be combined with each other between technical characteristic.
A specific embodiment of the invention is further described with reference to the accompanying drawing:
As shown in Figure 1, a kind of patient medical history quality control system, carries out the electronic health record that doctor makes for being supplied to school
Quality Control is to obtain Quality Control report；Include:
Database 1, for storing multiple electronic health records and Quality Control strategy, each above-mentioned electronic health record includes multiple element entries
With the case history content of each above-mentioned element entry of correspondence, above-mentioned case history content is made of the sub- content for corresponding to multiple interrogation points；
Quality Control module 2 connects above-mentioned database 1, for obtaining above-mentioned electronic health record and above-mentioned Quality Control from above-mentioned database 1
Strategy, and element entry is carried out to the above-mentioned element entry of each of above-mentioned electronic health record according to above-mentioned Quality Control strategy and detects to obtain element
Item testing result, and content is carried out to the above-mentioned case history content of each of above-mentioned electronic health record according to above-mentioned Quality Control strategy respectively
Detection obtains content detection as a result, and generating above-mentioned Quality Control report according to above-mentioned element entry testing result and above content testing result
It accuses.
In the present embodiment, hospital can carry out Quality Control operation after case history completes, to improve electronic health record
Accuracy, specifically, system can provide evaluation to this medical record writing process and generate corresponding after the completion of electronics patient medical history
Quality Control report, Quality Control report include the case history of doctor's interrogation effective percentage of corresponding case history content, corresponding element prime implicant and case history content
Complete quality etc.；
By the behavioural analysis and feedback reported based on Quality Control, feedback training, Jin Ergui are carried out to the behavioural habits of doctor
Fan doctor sees a doctor behavior, reinforces interrogation precision and efficiency, improves the standard rate of medical record writing；
Patient medical history Quality Control department is supported to carry out quality control to full Out-patient Department case history simultaneously, to patient medical history performance
It gives and objectively evaluates, data foundation is provided to patient medical history specification writing, improve the quality of hospital's entirety patient medical history.
In preferred embodiment, above-mentioned school includes multiple departments, and each department includes multiple above-mentioned doctors.
In preferred embodiment, above-mentioned element entry detection includes judging whether the above-mentioned element entry in above-mentioned electronic health record accords with
It closes preset quantity and default type and obtains above-mentioned element entry testing result.
In the present embodiment, element Quality Control is to judge the element type of case history missing according to customized Quality Control element entry,
And make prompting (display color changes on the right side of case history)
In preferred embodiment, above content detection is including judging the above-mentioned of the above-mentioned case history content in above-mentioned electronic health record
Whether interrogation point meets default interrogation point quantity and presets sub- content and obtain above content testing result.
In the present embodiment, whole pre- by judging whether to have contained in the corresponding case history content of each element entry
If the interrogation point of quantity and sub- content, judge whether doctor has been write comprehensively in all illness descriptions that the element entry is covered etc.
Hold.
In preferred embodiment, above-mentioned database 1 is also used to store the every other above-mentioned doctor with above-mentioned doctor with department
Raw first compares case history；
Above-mentioned quality Control module 2 is also used to obtain with the above-mentioned electronic health record of above-mentioned doctor from above-mentioned database 1 with identical
Above-mentioned the first of diagnostic result compares case history, and above-mentioned electronic health record and above-mentioned first are compared case history and carry out content comparison, with
Obtain the first comparing result；
Above-mentioned Quality Control report includes above-mentioned first comparison result.
In the present embodiment, doctor is after submitting case history every time, while providing Quality Control scoring, also to the sheet of the doctor
Secondary medical record writing content compares and analyzes, i.e., the standard medical record templates content comparison diagnosed same as department provides the doctor
The feedback of this interrogation point deletion condition.
In preferred embodiment, above-mentioned database 1 is also used to store the second ratio identical with the disease of above-mentioned electronic health record
To case history；
Above-mentioned quality Control module 2, which is also used to obtain from above-mentioned database 1, compares case history with above-mentioned second, and above-mentioned electronics is sick
It goes through and compares case history progress content comparison with above-mentioned second, to obtain the second comparing result；
Above-mentioned Quality Control report includes above-mentioned second comparison result.
In the present embodiment, after the completion of patient medical history, system can provide evaluation to this medical record writing process, compare with disease
Kind anamnesis is write in the writing of standard as defined in situation and the disease, and the writing quality of current case history is fed back.
In preferred embodiment, above-mentioned quality Control module 2 is according to above-mentioned element entry testing result and above content testing result
Generating above-mentioned Quality Control report includes the scores of medical records for generating corresponding above-mentioned element entry testing result.
In preferred embodiment, above-mentioned quality Control module 2 also provides for checking using day, the moon as the period respectively to hospital side
State the above-mentioned scores of medical records of electronic health record.
In the present embodiment, when scores of medical records is that case history is submitted, how much the case history score is prompted, where is deduction of points item.Disease
Per diem statistics case history number and scoring situation can be divided into and monthly count case history number and scoring situation by going through Quality Control statistics.
By description and accompanying drawings, the exemplary embodiments of the specific structure of specific embodiment are given, based on present invention essence
Mind can also make other conversions.Although foregoing invention proposes existing preferred embodiment, however, these contents are not intended as
Limitation.
For a person skilled in the art, after reading above description, various changes and modifications undoubtedly be will be evident.
Therefore, appended claims should regard the whole variations and modifications for covering true intention and range of the invention as.It is weighing
The range and content of any and all equivalences, are all considered as still belonging to the intent and scope of the invention within the scope of sharp claim.
Claims (8)
1. a kind of patient medical history quality control system, which is characterized in that carried out for being supplied to school to the electronic health record that doctor makes
Quality Control is to obtain Quality Control report；Include:
Database, for storing multiple electronic health records and Quality Control strategy, each electronic health record includes multiple element entries and right
Answer the case history content of each element entry, the case history content is made of the sub- content for corresponding to multiple interrogation points；
Quality Control module connects the database, for obtaining the electronic health record and the Quality Control strategy from the database, and
Element entry is carried out respectively to each of the electronic health record element entry according to the Quality Control strategy to detect to obtain element entry
Testing result, and content inspection is carried out to each of the electronic health record case history content according to the Quality Control strategy respectively
Content detection is measured as a result, and generating the Quality Control report according to the element entry testing result and the content detection result
It accuses.
2. patient medical history quality control system according to claim 1, which is characterized in that the school includes multiple departments, often
A department includes multiple doctors.
3. patient medical history quality control system according to claim 1, which is characterized in that the element entry detection includes judging institute
State whether the element entry in electronic health record meets preset quantity and default type and obtain the element entry testing result.
4. patient medical history quality control system according to claim 1, which is characterized in that the content detection includes described in judgement
Whether the interrogation point of the case history content in electronic health record meets default interrogation point quantity and presets sub- content and obtain
The content detection result.
5. patient medical history quality control system according to claim 2, which is characterized in that the database is also used to store and institute
Doctor is stated with the first comparison case history of the every other doctor of department；
The quality Control module, which is also used to obtain from the database, has same diagnostic knot with the electronic health record of the doctor
Described the first of fruit compares case history, and the electronic health record and described first are compared case history and carry out content comparison, to obtain the
One comparing result；
The Quality Control report includes first comparison result.
6. patient medical history quality control system according to claim 2, which is characterized in that the database is also used to store and institute
The disease identical second for stating electronic health record compares case history；
The quality Control module, which is also used to obtain from the database, compares case history with described second, and by the electronic health record and institute
It states the second comparison case history and carries out content comparison, to obtain the second comparing result；
The Quality Control report includes second comparison result.
7. patient medical history quality control system according to claim 1, which is characterized in that the quality Control module is according to the element
It includes generating the corresponding element entry testing result that item testing result and the content detection result, which generate the Quality Control report,
Scores of medical records.
8. patient medical history quality control system according to claim 1, which is characterized in that the quality Control module also provide for
The scores of medical records of the electronic health record is checked using day, the moon as the period respectively by hospital side.
Priority Applications (1)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CN201811642364.4A CN109887558A (en) | 2018-12-29 | 2018-12-29 | A kind of patient medical history quality control system |
Applications Claiming Priority (1)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CN201811642364.4A CN109887558A (en) | 2018-12-29 | 2018-12-29 | A kind of patient medical history quality control system |
Publications (1)
| Publication Number | Publication Date |
|---|---|
| CN109887558A true CN109887558A (en) | 2019-06-14 |
Family
ID=66925433
Family Applications (1)
| Application Number | Title | Priority Date | Filing Date |
|---|---|---|---|
| CN201811642364.4A Pending CN109887558A (en) | 2018-12-29 | 2018-12-29 | A kind of patient medical history quality control system |
Country Status (1)
| Country | Link |
|---|---|
| CN (1) | CN109887558A (en) |
Cited By (4)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN110751994A (en) * | 2019-08-28 | 2020-02-04 | 云知声智能科技股份有限公司 | Differential display method and system for medical record template |
| CN111967241A (en) * | 2020-09-03 | 2020-11-20 | 卫宁健康科技集团股份有限公司 | Medical record writing quality control method and system |
| CN112582050A (en) * | 2019-09-29 | 2021-03-30 | 上海市嘉定区南翔医院 | Intelligent monitoring system and method |
| CN115879179A (en) * | 2023-02-24 | 2023-03-31 | 忻州师范学院 | Abnormal medical record detection device |
Citations (8)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN1609816A (en) * | 2003-10-24 | 2005-04-27 | 英业达股份有限公司 | Data testing system and method |
| CN101714191A (en) * | 2009-11-13 | 2010-05-26 | 无锡曼荼罗软件有限公司 | Quality control method and device for electronic medical records |
| CN103577717A (en) * | 2013-11-25 | 2014-02-12 | 方正国际软件有限公司 | Content quality control device and method for medical history document |
| CN105808951A (en) * | 2016-03-10 | 2016-07-27 | 宁波金唐软件有限公司 | Quality control method and apparatus for electronic medical record |
| CN107978343A (en) * | 2017-11-02 | 2018-05-01 | 刘莉 | The evaluation system of electronic health record |
| JP2018116554A (en) * | 2017-01-19 | 2018-07-26 | 株式会社島津製作所 | Electronic medical chart system and electronic medical chart creation program |
| CN108447534A (en) * | 2018-05-18 | 2018-08-24 | 灵玖中科软件（北京）有限公司 | A kind of electronic health record data quality management method based on NLP |
| CN109035094A (en) * | 2018-08-01 | 2018-12-18 | 杭州认知网络科技有限公司 | Teaching method, device and terminal device based on artificial intelligence |
-
2018
- 2018-12-29 CN CN201811642364.4A patent/CN109887558A/en active Pending
Patent Citations (8)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN1609816A (en) * | 2003-10-24 | 2005-04-27 | 英业达股份有限公司 | Data testing system and method |
| CN101714191A (en) * | 2009-11-13 | 2010-05-26 | 无锡曼荼罗软件有限公司 | Quality control method and device for electronic medical records |
| CN103577717A (en) * | 2013-11-25 | 2014-02-12 | 方正国际软件有限公司 | Content quality control device and method for medical history document |
| CN105808951A (en) * | 2016-03-10 | 2016-07-27 | 宁波金唐软件有限公司 | Quality control method and apparatus for electronic medical record |
| JP2018116554A (en) * | 2017-01-19 | 2018-07-26 | 株式会社島津製作所 | Electronic medical chart system and electronic medical chart creation program |
| CN107978343A (en) * | 2017-11-02 | 2018-05-01 | 刘莉 | The evaluation system of electronic health record |
| CN108447534A (en) * | 2018-05-18 | 2018-08-24 | 灵玖中科软件（北京）有限公司 | A kind of electronic health record data quality management method based on NLP |
| CN109035094A (en) * | 2018-08-01 | 2018-12-18 | 杭州认知网络科技有限公司 | Teaching method, device and terminal device based on artificial intelligence |
Cited By (5)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN110751994A (en) * | 2019-08-28 | 2020-02-04 | 云知声智能科技股份有限公司 | Differential display method and system for medical record template |
| CN110751994B (en) * | 2019-08-28 | 2022-04-01 | 云知声智能科技股份有限公司 | Differential display method and system for medical record template |
| CN112582050A (en) * | 2019-09-29 | 2021-03-30 | 上海市嘉定区南翔医院 | Intelligent monitoring system and method |
| CN111967241A (en) * | 2020-09-03 | 2020-11-20 | 卫宁健康科技集团股份有限公司 | Medical record writing quality control method and system |
| CN115879179A (en) * | 2023-02-24 | 2023-03-31 | 忻州师范学院 | Abnormal medical record detection device |
Similar Documents
| Publication | Publication Date | Title |
|---|---|---|
| CN109887558A (en) | A kind of patient medical history quality control system | |
| US20200302296A1 (en) | Systems and method for optimizing educational outcomes using artificial intelligence | |
| Muis et al. | Using a multitrait‐multimethod analysis to examine conceptual similarities of three self‐regulated learning inventories | |
| Edgcomb et al. | Machine learning, natural language processing, and the electronic health record: innovations in mental health services research | |
| Buckingham et al. | Classifying clinical decision making: interpreting nursing intuition, heuristics and medical diagnosis | |
| Lee | Correlation and causation in the study of personality | |
| Fritz et al. | A comprehensive review of reporting practices in psychological journals: Are effect sizes really enough? | |
| US10061894B2 (en) | Systems and methods for medical referral analytics | |
| Youngstrom et al. | Commentary: Moving toward cost-effectiveness in using psychophysiological measures in clinical assessment: Validity, decision making, and adding value | |
| US11392854B2 (en) | Systems and methods for implementing generated alimentary instruction sets based on vibrant constitutional guidance | |
| US20200380458A1 (en) | Systems and methods for arranging transport of alimentary components | |
| Sharpe et al. | Research methods, statistics and evidence-based practice | |
| Kralewski et al. | Factors influencing physician use of clinical electronic information technologies after adoption by their medical group practices | |
| CN101204320A (en) | System for cross-acquisition of physiological and psychological information | |
| Zhou et al. | Evidence-based assessment of ADHD diagnosis in children and adolescents | |
| Kang et al. | Q-matrix refinement based on item fit statistic RMSEA | |
| King et al. | Using machine learning to predict the information seeking behavior of clinicians using an electronic medical record system | |
| Gorelick et al. | Predicting need for hospitalization in acute pediatric asthma | |
| CN111339285A (en) | BP neural network-based enterprise resume screening method and system | |
| Plant et al. | Heavy drinking by young British women gives cause for concern | |
| Hwang et al. | Representation of ophthalmology concepts by electronic systems: intercoder agreement among physicians using controlled terminologies | |
| US11222727B2 (en) | Systems and methods for generating alimentary instruction sets based on vibrant constitutional guidance | |
| Murray et al. | The accuracy of the Learning Disability Screening Questionnaire (LDSQ) in classifying severity of impairment: A brief report | |
| Prigmore | An analysis of rater reliability on the Glueck scale for the prediction of juvenile delinquency | |
| Meissel | Quantitative analysis selection in education: Potential impacts on researchers' conclusions |
Legal Events
| Date | Code | Title | Description |
|---|---|---|---|
| PB01 | Publication | ||
| PB01 | Publication | ||
| SE01 | Entry into force of request for substantive examination | ||
| SE01 | Entry into force of request for substantive examination | ||
| RJ01 | Rejection of invention patent application after publication |
Application publication date: 20190614 |