CN110751994A - Differential display method and system for medical record template - Google Patents
Differential display method and system for medical record template Download PDFInfo
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Abstract
The invention provides a differential display method and a differential display system of a medical record template, which are different from the prior art that medical record filling operation is carried out on all patients by only adopting a single-form electronic medical record template, can comprehensively and accurately determine medical record filling items which are possibly wrongly filled due to differential information in the electronic medical record template, thereby effectively improving the comprehensiveness of the subsequent inspection of the filled electronic medical record, and can also carry out adaptive matching processing according to marked nodes and the sex or age information of the patients to ensure that the finally displayed medical record meets the requirement of the current patient attribute, thereby effectively avoiding obvious filling errors of the medical record and improving the accuracy of filling the content of the medical record.
Description
Technical Field
The invention relates to the technical field of electronic medical record data processing, in particular to a differential display method and system of medical record templates.
Background
Currently, the medical diagnosis data processing is developing along with the direction of intellectualization, which requires that the diagnosis data formed in the disease diagnosis process needs to be converted into the electronic data format, thereby facilitating the subsequent viewing and processing of the diagnosis data. Although, existing electronic medical record writing systems already provide a ready-made electronic medical record template, which is convenient for a doctor to directly fill in matching items in the electronic medical record template during the writing process. However, in the actual electronic medical record writing process, because different patients have differences such as gender, some filling items in the electronic medical record template are only suitable for patients with specific gender, and if a doctor does not notice whether the gender of the current patient is in obvious conflict with the filling items in the filling process, the finally written electronic medical record has errors, thereby affecting the accuracy of subsequent patient disease diagnosis. In order to save the writing time of the electronic medical record and improve the writing efficiency of the electronic medical record, the existing electronic medical record writing system usually only provides a single-form universal electronic medical record template, and different electronic medical record templates are not provided adaptively according to the difference of the gender of the patient, which undoubtedly increases the error rate of the electronic medical record writing. Therefore, an efficient and accurate differential display method and system for medical record templates aiming at different types and other differences of patients is urgently needed in the prior art.
Disclosure of Invention
Aiming at the defects in the prior art, the invention provides a differential display method and a differential display system for a medical record template, wherein the differential display method for the medical record template comprises the following steps: step (1), acquiring node information to be processed of a current medical record template, and executing adaptive node marking processing according to the node information to be processed; step (2), quality control processing is carried out on the current medical record template, patient attribute information corresponding to the current medical record template is obtained at the same time, and the marked nodes and the corresponding medical record document contents are associated according to the patient attribute information; step (3), according to the matching judgment result between the marked node and the patient attribute information, differential display operation is performed on the current medical record module; correspondingly, the differential display system of the medical record template adaptively displays the medical record template based on the mode. Therefore, the differential display method and the differential display system of the medical record template are different from the prior art that medical record filling operation is carried out on all patients by only adopting a single-form electronic medical record template, and medical record filling items related to different difference information such as gender or age are determined in the electronic medical record template as to-be-processed node information by marking the electronic medical record template with the different difference information in advance, so that the medical record filling items which are possibly wrongly filled due to the difference information can be completely and accurately determined in the electronic medical record template, and the comprehensiveness of the subsequent inspection of the filled electronic medical record is effectively improved; secondly, the method and the system can also carry out quality control processing on the current electronic medical record template according to the node information to be processed so as to obtain the potential defect content in the electronic medical record template, thereby improving the accuracy and the effectiveness of the defect content inspection on the electronic medical record template; finally, the method and the system also carry out adaptive matching processing according to the marked nodes and the information about the gender or the age of the patient to ensure that the finally displayed medical record meets the requirements of the current patient attributes, thereby effectively avoiding obvious filling errors of the medical record and improving the accuracy of filling the content of the medical record.
The invention provides a differential display method of medical record templates, which is characterized by comprising the following steps:
step (1), acquiring node information to be processed of a current medical record template, and executing adaptive node marking processing according to the node information to be processed;
step (2), performing quality control processing on a current medical record template, simultaneously acquiring patient attribute information corresponding to the current medical record template, and associating marked nodes and medical record document contents corresponding to the marked nodes according to the patient attribute information;
step (3), according to the matching judgment result between the marked node and the patient attribute information, differential display operation is performed on the current medical record module;
further, in the step (1), acquiring information of nodes to be processed of the current medical record template, and performing adaptive node marking processing according to the information of the nodes to be processed specifically includes,
step (101), acquiring all medical record content filling item information corresponding to the current medical record template, and performing node identification processing on all medical record content filling item information so as to determine nodes existing in the current medical record template and positions of the nodes in the template content;
step (102), judging the current document filling state of the node according to the determined existing node and the position of the node in the template content, and obtaining the information of the node to be processed according to the document filling state;
step (103), if the information of the node to be processed indicates that the corresponding node is in a state that the document content is not written, the corresponding node is marked as a first type node, and if the information of the node to be processed indicates that the corresponding node is in a state that the document content is written, the corresponding node is marked as a second type node;
further, in the step (2), the quality control processing is performed on the current medical record template, the patient attribute information corresponding to the current medical record template is obtained at the same time, and the nodes associated with the marks and the medical record document contents corresponding to the nodes specifically include according to the patient attribute information,
step (201), traversing all the document contents of the current medical record template to search at least one of document logic defects, document wrongly written character defects and document symbol defects so as to perform the quality control processing;
step (202), acquiring gender information and/or age information of the patient in the current medical record template as the patient attribute information, and performing keyword extraction processing in different modes on the first type node and the second type node according to the patient attribute information;
step (203), according to the result of the keyword extraction processing, respectively performing first association processing on the first type node and the corresponding medical record document content thereof, and performing second association processing on the second type node and the corresponding medical record document content thereof;
further, in the step (202), acquiring gender information and/or age information of the patient in the current medical record template as the patient attribute information, and performing keyword extraction processing in different modes on the first type node and the second type node according to the patient attribute information specifically includes,
step (2021), converting the gender information and/or the age information into gender-related disease symptom information and/or age-related disease symptom information according to a preset general disease database;
step (2022), for the first type node, extracting the content keyword from the first type node according to the gender-related disease symptom information and/or the age-related disease symptom information;
step (2023), for the second type node, performing extraction processing of filling content keywords for the second type node according to the gender-related disease symptom information and/or age-related disease symptom information;
or,
in the step (203), the first association process includes constructing a character mapping relationship between the keywords in the first type node and the corresponding medical record document content;
or,
the second association processing comprises the step of constructing a character mapping relation between the keywords in the second type node and the corresponding medical record document content;
further, in the step (3), the performing differentiated display operation on the current medical record module according to the matching judgment result between the marked node and the patient attribute information specifically includes,
step (301), if the matching judgment result indicates that the marked node is matched with the patient attribute information, generating a first display operation indication signal;
step (302), if the matching judgment result indicates that the marked node is not matched with the patient attribute information, a second display operation indication signal is generated;
and (303) displaying all the document contents of the current medical record template according to the first display operation indication signal, and not displaying the document contents corresponding to the marked nodes which do not match with the patient attribute information in the current medical record template according to the second display operation indication signal.
The invention also provides a differential display system of the medical record template, which is characterized in that:
the differential display system of the medical record template comprises a node information acquisition module, a node marking module, a quality control module, a node association module and a display adjustment module; wherein,
the node information acquisition module is used for acquiring the information of the node to be processed of the current medical record template;
the node marking module is used for executing adaptive node marking processing according to the node information to be processed;
the quality control module is used for performing quality control processing on the current medical record template;
the node association module is used for associating the marked nodes and the corresponding medical record document contents according to the patient attribute information corresponding to the current medical record template;
the display adjusting module is used for executing differential display operation on the current medical record module according to the matching judgment result between the marked node and the patient attribute information;
further, the node information acquisition module comprises a node identification submodule, a node positioning submodule and a node classification submodule; wherein,
the node identification submodule is used for carrying out node identification processing on all medical record content filling item information according to all medical record content filling item information corresponding to the current medical record template;
the node positioning sub-module is used for determining the nodes of the current medical record template and the positions of the nodes in the template content;
the node classification submodule is used for marking the corresponding node as a first type node when the information of the node to be processed indicates that the corresponding node is in a state that the document content is not written, and marking the corresponding node as a second type node when the information of the node to be processed indicates that the corresponding node is in a state that the document content is written;
further, the quality control module executes the quality control processing, specifically including traversing all the document contents of the current medical record template to search at least one of document logic defects, document wrongly written character defects and document symbol defects;
the node association module is also used for respectively carrying out first association processing on the first type node and the corresponding medical record document content thereof and carrying out second association processing on the second type node and the corresponding medical record document content thereof according to the patient attribute information with the gender information and/or the age information of the patient;
further, the node association module may include a disease information conversion sub-module and a mapping relation construction sub-module; wherein,
the disease information conversion submodule is used for converting the sex information and/or the age information into sex-related disease symptom information and/or age-related disease symptom information according to a preset universal disease database;
the mapping relation construction submodule is used for constructing a character mapping relation between the keywords contained in the first type node or the second type node and the medical record document contents corresponding to the keywords;
further, the display adjustment module is further configured to display all document contents of the current medical record template when the matching determination result indicates that the marked node matches the patient attribute information;
or,
the display adjustment module is further configured to, when the matching determination result indicates that the marked node is not matched with the patient attribute information, not display the document content corresponding to the marked node that is not matched with the patient attribute information in the current medical record template.
Compared with the prior art, the differential display method and the differential display system of the medical record template are different from the prior art that only a single-form electronic medical record template is adopted to fill in medical records of all patients, and the marking operation of different differential information such as gender or age is carried out on the electronic medical record template in advance to determine medical record filling items related to the differential information in the electronic medical record template as node information to be processed, so that the medical record filling items which are possibly wrongly filled due to the differential information can be comprehensively and accurately determined in the electronic medical record template, and the comprehensiveness of the follow-up inspection of the filled-in electronic medical record is effectively improved; secondly, the method and the system can also carry out quality control processing on the current electronic medical record template according to the node information to be processed so as to obtain the potential defect content in the electronic medical record template, thereby improving the accuracy and the effectiveness of the defect content inspection on the electronic medical record template; finally, the method and the system also carry out adaptive matching processing according to the marked nodes and the information about the gender or the age of the patient to ensure that the finally displayed medical record meets the requirements of the current patient attributes, thereby effectively avoiding obvious filling errors of the medical record and improving the accuracy of filling the content of the medical record.
Additional features and advantages of the invention will be set forth in the description which follows, and in part will be obvious from the description, or may be learned by practice of the invention. The objectives and other advantages of the invention will be realized and attained by the structure particularly pointed out in the written description and claims hereof as well as the appended drawings.
The technical solution of the present invention is further described in detail by the accompanying drawings and embodiments.
Drawings
In order to more clearly illustrate the embodiments of the present invention or the technical solutions in the prior art, the drawings used in the description of the embodiments or the prior art will be briefly described below, it is obvious that the drawings in the following description are only some embodiments of the present invention, and for those skilled in the art, other drawings can be obtained according to the drawings without creative efforts.
Fig. 1 is a schematic flow chart of a differential display method for medical record templates according to the present invention.
Fig. 2 is a schematic structural diagram of a differential display system of medical record templates provided by the present invention.
Detailed Description
The technical solutions in the embodiments of the present invention will be clearly and completely described below with reference to the drawings in the embodiments of the present invention, and it is obvious that the described embodiments are only a part of the embodiments of the present invention, and not all of the embodiments. All other embodiments, which can be derived by a person skilled in the art from the embodiments given herein without making any creative effort, shall fall within the protection scope of the present invention.
Fig. 1 is a schematic flow chart of a differential display method for medical record templates according to an embodiment of the present invention. The differential display method of the medical record template comprises the following steps:
and (1) acquiring to-be-processed node information of the current medical record template, and executing adaptive node marking processing according to the to-be-processed node information.
Preferably, in the step (1), acquiring node information to be processed of the current medical record template, and performing adaptive node marking processing according to the node information to be processed specifically includes,
step (101), acquiring all medical record content filling item information corresponding to the current medical record template, and performing node identification processing on all medical record content filling item information so as to determine nodes existing in the current medical record template and positions of the nodes in the template content;
step (102), according to the determined existing node and the position of the node in the template content, judging the current document filling state of the node, and obtaining the information of the node to be processed according to the document filling state;
and (103) if the information of the node to be processed indicates that the corresponding node is in the state that the document content is not written, marking the corresponding node as a first type node, and if the information of the node to be processed indicates that the corresponding node is in the state that the document content is written, marking the corresponding node as a second type node.
And (2) performing quality control processing on the current medical record template, simultaneously acquiring the patient attribute information corresponding to the current medical record template, and associating the marked nodes and the medical record document contents corresponding to the marked nodes according to the patient attribute information.
Preferably, in the step (2), the quality control processing is performed on the current medical record template, the patient attribute information corresponding to the current medical record template is obtained at the same time, and the nodes associated with the marks and the medical record document contents corresponding to the nodes specifically include, according to the patient attribute information,
step (201), traversing all the document contents of the current medical record template to search at least one of document logic defects, document wrongly written character defects and document symbol defects, so as to perform the quality control processing;
step (202), acquiring gender information and/or age information of the patient in the current medical record template, taking the gender information and/or age information as the attribute information of the patient, and respectively performing different modes of keyword extraction processing on the first type node and the second type node according to the attribute information of the patient;
and (203) respectively performing first association processing on the first type node and the corresponding medical record document content thereof and performing second association processing on the second type node and the corresponding medical record document content thereof according to the keyword extraction processing result.
Preferably, in the step (202), acquiring the gender information and/or the age information of the patient in the current medical record template as the patient attribute information, and performing different-mode keyword extraction processing on the first type node and the second type node according to the patient attribute information specifically includes,
step (2021), converting the sex information and/or age information into sex-related disease symptom information and/or age-related disease symptom information according to a preset general disease database;
step (2022), for the first type node, extracting the content keyword from the first type node according to the gender-related disease symptom information and/or the age-related disease symptom information;
and (2023) for the second type node, performing extraction processing of filling content keywords for the second type node according to the gender-related disease symptom information and/or age-related disease symptom information.
Preferably, in the step (203), the first association process includes constructing a text mapping relationship between the keywords in the first type node and the corresponding medical record document contents.
Preferably, in the step (203), the second association process includes constructing a text mapping relationship between the keywords in the second type node and the corresponding medical record document content.
And (3) performing differentiated display operation on the current medical record module according to the matching judgment result between the marked node and the patient attribute information.
Preferably, in the step (3), the performing differentiated display operation on the current medical record module according to the matching judgment result between the marked node and the patient attribute information specifically includes,
step (301), if the matching judgment result indicates that the marked node is matched with the patient attribute information, generating a first display operation indication signal;
step (302), if the matching judgment result indicates that the marked node is not matched with the patient attribute information, a second display operation indication signal is generated;
and (303) displaying all the document contents of the current medical record template according to the first display operation indication signal, and not displaying the document contents corresponding to the marked node which does not match with the patient attribute information in the current medical record template according to the second display operation indication signal.
Fig. 2 is a schematic structural diagram of a differentiated display system of medical record templates according to an embodiment of the present invention. The differential display system of the medical record template comprises a node information acquisition module, a node marking module, a quality control module, a node association module and a display adjustment module. Wherein,
the node information acquisition module is used for acquiring the information of the node to be processed of the current medical record template;
the node marking module is used for executing adaptive node marking processing according to the node information to be processed;
the quality control module is used for carrying out quality control processing on the current medical record template;
the node association module is used for associating the marked nodes and the corresponding medical record document contents according to the patient attribute information corresponding to the current medical record template;
the display adjusting module is used for performing differentiated display operation on the current medical record module according to a matching judgment result between the marked node and the patient attribute information.
Preferably, the node information acquisition module comprises a node identification submodule, a node positioning submodule and a node classification submodule;
preferably, the node identification submodule is configured to perform node identification processing on all medical record content filling item information according to all medical record content filling item information corresponding to the current medical record template;
preferably, the node positioning sub-module is configured to determine the node existing in the current medical record template and the position of the node in the template content;
preferably, the node classification submodule is configured to mark the corresponding node as a first type node when the to-be-processed node information indicates that the corresponding node is in a state where the document content is unwritten, and mark the corresponding node as a second type node when the to-be-processed node information indicates that the corresponding node is in a state where the document content is written;
preferably, the quality control module executes the quality control processing specifically including traversing all document contents of the current medical record template for at least one of document logic defect, document wrongly written character defect and document symbol defect;
preferably, the node association module further performs a first association process on the first type node and its corresponding medical record document content, and a second association process on the second type node and its corresponding medical record document content, respectively, according to the patient attribute information having gender information and/or age information of the patient;
preferably, the node association module may include a disease information conversion sub-module and a mapping relation construction sub-module;
preferably, the disease information conversion sub-module is configured to convert the sex information and/or the age information into sex-related disease symptom information and/or age-related disease symptom information according to a preset general disease database;
preferably, the mapping relationship construction sub-module is configured to construct a text mapping relationship between the keywords included in each of the first type nodes or the second type nodes and the medical record contents corresponding to each of the first type nodes or the second type nodes;
preferably, the display adjustment module is further configured to display all document contents of the current medical record template when the matching determination result indicates that the marked node matches with the patient attribute information;
preferably, the display adjusting module is further configured to, when the matching determination result indicates that the marked node does not match the patient attribute information, not display the document content corresponding to the marked node that does not match the patient attribute information in the current medical record template.
It can be known from the content of the above embodiment that the differential display method and system of the medical record template are different from the prior art that only a single form of electronic medical record template is adopted to perform medical record filling operation on all patients, and the marking operation on different differential information such as gender or age is performed on the electronic medical record template in advance to determine the medical record filling item associated with the differential information in the electronic medical record template as the node information to be processed, so that the medical record filling item which may be wrongly filled due to the differential information can be completely and accurately determined in the electronic medical record template, thereby effectively improving the comprehensiveness of the subsequent inspection of the filled electronic medical record; secondly, the method and the system can also carry out quality control processing on the current electronic medical record template according to the node information to be processed so as to obtain the potential defect content in the electronic medical record template, thereby improving the accuracy and the effectiveness of the defect content inspection on the electronic medical record template; finally, the method and the system also carry out adaptive matching processing according to the marked nodes and the information about the gender or the age of the patient to ensure that the finally displayed medical record meets the requirements of the current patient attributes, thereby effectively avoiding obvious filling errors of the medical record and improving the accuracy of filling the content of the medical record.
It will be apparent to those skilled in the art that various changes and modifications may be made in the present invention without departing from the spirit and scope of the invention. Thus, if such modifications and variations of the present invention fall within the scope of the claims of the present invention and their equivalents, the present invention is also intended to include such modifications and variations.
Claims (10)
1. A differential display method of medical record templates is characterized by comprising the following steps:
step (1), acquiring node information to be processed of a current medical record template, and executing adaptive node marking processing according to the node information to be processed;
step (2), performing quality control processing on a current medical record template, simultaneously acquiring patient attribute information corresponding to the current medical record template, and associating marked nodes and medical record document contents corresponding to the marked nodes according to the patient attribute information;
and (3) performing differentiated display operation on the current medical record module according to the matching judgment result between the marked node and the patient attribute information.
2. The method for differentiated display of medical record templates according to claim 1, wherein:
in the step (1), acquiring the information of the node to be processed of the current medical record template, and executing adaptive node marking processing according to the information of the node to be processed specifically comprises,
step (101), acquiring all medical record content filling item information corresponding to the current medical record template, and performing node identification processing on all medical record content filling item information so as to determine nodes existing in the current medical record template and positions of the nodes in the template content;
step (102), judging the current document filling state of the node according to the determined existing node and the position of the node in the template content, and obtaining the information of the node to be processed according to the document filling state;
and (103) if the information of the nodes to be processed indicates that the corresponding nodes are in the state that the document content is not written, marking the corresponding nodes as first type nodes, and if the information of the nodes to be processed indicates that the corresponding nodes are in the state that the document content is written, marking the corresponding nodes as second type nodes.
3. The method for differentiated display of medical record templates according to claim 2, wherein:
in the step (2), the quality control processing is performed on the current medical record template, the patient attribute information corresponding to the current medical record template is obtained at the same time, and the nodes associated with the marks and the medical record document contents corresponding to the nodes specifically include according to the patient attribute information,
step (201), traversing all the document contents of the current medical record template to search at least one of document logic defects, document wrongly written character defects and document symbol defects so as to perform the quality control processing;
step (202), acquiring gender information and/or age information of the patient in the current medical record template as the patient attribute information, and performing keyword extraction processing in different modes on the first type node and the second type node according to the patient attribute information;
and (203) respectively performing first association processing on the first type node and the medical record document content corresponding to the first type node and performing second association processing on the second type node and the medical record document content corresponding to the second type node according to the keyword extraction processing result.
4. The method for differentiated display of medical record templates according to claim 3, wherein:
in the step (202), acquiring gender information and/or age information of the patient in the current medical record template as the patient attribute information, and performing keyword extraction processing in different modes on the first type node and the second type node according to the patient attribute information specifically includes,
step (2021), converting the gender information and/or the age information into gender-related disease symptom information and/or age-related disease symptom information according to a preset general disease database;
step (2022), for the first type node, extracting the content keyword from the first type node according to the gender-related disease symptom information and/or the age-related disease symptom information;
step (2023), for the second type node, performing extraction processing of filling content keywords for the second type node according to the gender-related disease symptom information and/or age-related disease symptom information;
or,
in the step (203), the first association process includes constructing a character mapping relationship between the keywords in the first type node and the corresponding medical record document content;
or,
and the second association processing comprises the step of constructing a character mapping relation between the keywords in the second type node and the medical record document content corresponding to the keywords.
5. The method for differentiated display of medical record templates according to claim 1, wherein:
in the step (3), the performing differentiated display operation on the current medical record module according to the matching judgment result between the marked node and the patient attribute information specifically includes,
step (301), if the matching judgment result indicates that the marked node is matched with the patient attribute information, generating a first display operation indication signal;
step (302), if the matching judgment result indicates that the marked node is not matched with the patient attribute information, a second display operation indication signal is generated;
and (303) displaying all the document contents of the current medical record template according to the first display operation indication signal, and not displaying the document contents corresponding to the marked nodes which do not match with the patient attribute information in the current medical record template according to the second display operation indication signal.
6. A differentiation display system of case history template which characterized in that:
the differential display system of the medical record template comprises a node information acquisition module, a node marking module, a quality control module, a node association module and a display adjustment module; wherein,
the node information acquisition module is used for acquiring the information of the node to be processed of the current medical record template;
the node marking module is used for executing adaptive node marking processing according to the node information to be processed;
the quality control module is used for performing quality control processing on the current medical record template;
the node association module is used for associating the marked nodes and the corresponding medical record document contents according to the patient attribute information corresponding to the current medical record template;
the display adjusting module is used for executing differential display operation on the current medical record module according to the matching judgment result between the marked node and the patient attribute information.
7. The differential display system of medical record templates of claim 6, wherein:
the node information acquisition module comprises a node identification submodule, a node positioning submodule and a node classification submodule; wherein,
the node identification submodule is used for carrying out node identification processing on all medical record content filling item information according to all medical record content filling item information corresponding to the current medical record template;
the node positioning sub-module is used for determining the nodes of the current medical record template and the positions of the nodes in the template content;
the node classification submodule is used for marking the corresponding node as a first type node when the information of the node to be processed indicates that the corresponding node is in a state that the document content is not written, and marking the corresponding node as a second type node when the information of the node to be processed indicates that the corresponding node is in a state that the document content is written.
8. The system for differentiated display of medical record templates of claim 7, wherein:
the quality control module executes the quality control processing, and specifically comprises the steps of traversing all the document contents of the current medical record template to search at least one of document logic defects, document wrongly written character defects and document symbol defects;
the node association module is further used for respectively performing first association processing on the first type nodes and the medical record document contents corresponding to the first type nodes and performing second association processing on the second type nodes and the medical record document contents corresponding to the second type nodes according to the patient attribute information with the gender information and/or the age information of the patient.
9. The differential display system of medical record templates of claim 8, wherein:
the node association module can comprise a disease information conversion sub-module and a mapping relation construction sub-module;
wherein,
the disease information conversion submodule is used for converting the sex information and/or the age information into sex-related disease symptom information and/or age-related disease symptom information according to a preset universal disease database;
the mapping relation construction submodule is used for constructing a character mapping relation between the keywords contained in the first type node or the second type node and the medical record document content corresponding to the keywords.
10. The differential display system of medical record templates of claim 6, wherein:
the display adjusting module is further used for displaying all document contents of the current medical record template when the matching judgment result indicates that the marked node is matched with the patient attribute information;
or,
the display adjustment module is further configured to, when the matching determination result indicates that the marked node is not matched with the patient attribute information, not display the document content corresponding to the marked node that is not matched with the patient attribute information in the current medical record template.
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