CN110765734A - Electronic medical record editor based on BS framework - Google Patents
Electronic medical record editor based on BS framework Download PDFInfo
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- CN110765734A CN110765734A CN201911009394.6A CN201911009394A CN110765734A CN 110765734 A CN110765734 A CN 110765734A CN 201911009394 A CN201911009394 A CN 201911009394A CN 110765734 A CN110765734 A CN 110765734A
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- 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 invention relates to the technical field of medical service, and discloses an electronic medical record editor based on a BS (browser/server) framework, which comprises a medical record editing module, a small template module, a medical record component module, a node storage module, a medical record storage module and a template storage module; the editing module is divided into three working modes, components in the medical record component module are called through the medical record editing module and small templates in the small template module are called to generate an electronic medical record template in the design mode, the design of the electronic medical record template is achieved, and the edited electronic medical record template is transmitted to the template storage module to be stored; under the read-write mode, the text information related to the illness state is input directly by calling the electronic medical record template designed in the template storage module, so that the electronic medical record is edited on line, the edited electronic medical record is stored in the medical record storage module, the operation flow is simplified, and the problems of unsatisfied functions, poor structuralization and complex use of the conventional electronic medical record editor are solved.
Description
Technical Field
The invention relates to the technical field of medical services, in particular to an electronic medical record editor based on a BS framework.
Background
The electronic medical record refers to a computer information system which supports the collection, storage and access of electronic medical record information in a medical institution and provides information processing and intelligent service functions by improving medical quality, guaranteeing medical safety and improving medical efficiency. The electronic medical record management plays an important role in hospital information management, and is a bridge and a link for maintaining information of hospitals and patients. The electronic medical record editor is the core and difficulty of the electronic medical record, and more than 80% of technical difficulties in the development of the electronic medical record system are concentrated on the electronic medical record editor. The electronic medical record editors on the market at present have the defects of unsatisfied functions, poor structuralization and complex use.
Disclosure of Invention
Based on the problems, the invention provides an electronic medical record editor based on a BS framework, which adopts three working modes, and generates an electronic medical record template by calling components in a medical record component module and calling a small template in a small template module through a medical record editing module in a design mode, so as to realize the design of the electronic medical record template and transmit the edited electronic medical record template to a template storage module for storage; under the read-write mode, the text information related to the illness state is input directly by calling the electronic medical record template designed in the template storage module, so that the electronic medical record is edited on line, the edited electronic medical record is stored in the medical record storage module, the operation flow is simplified, and the problems of unsatisfied functions, poor structuralization and complex use of the conventional electronic medical record editor are solved.
In order to solve the technical problems, the invention adopts the technical scheme that:
an electronic medical record editor based on a BS framework comprises a medical record editing module, a small template module, a medical record component module, a node storage module, a medical record storage module and a template storage module, wherein the small template module, the medical record component module, the medical record storage module and the template storage module are all in communication connection with the medical record editing module; the small template module and the node storage module are in communication connection with the medical record component module;
the node storage module is used for providing basic data of the medical record template component to the medical record component module, and the basic data of the component comprises a data element corresponding to the disease condition, a data set consisting of a plurality of data elements and a value range of the data element;
the medical record component module is used for forming and storing the basic data of the medical record template transmitted by the node storage module into components;
the small template module is used for providing an electronic medical record small template for the medical record editing module; the small template mainly comprises components and texts, wherein the texts with high use frequency and the corresponding components are extracted to be independently manufactured into the small template which is stored in the small template module;
the medical record editing module comprises three working modes, namely a design mode, a read-write mode and a read-only mode;
the medical record editing module is used for calling medical record components in the medical record component module and inputting corresponding texts in the design mode, and can also call and reference small templates in the small template module, add the medical record components and the small templates into the medical record templates, and then transmit the edited medical record templates to the template storage module for storage;
the medical record editing module is used for inputting a text related to a medical record into the medical record template in the read-write mode and storing the edited electronic medical record into the medical record storage module;
the medical record editor can directly display the edited medical record template in the read-only mode;
the electronic medical record editor also comprises a medical record printing module, the medical record printing module is in communication connection with the medical record editor, and the medical record editing module can print the edited electronic medical record through the medical record printing module.
Furthermore, the medical record editing module also supports setting styles of text contents, including bolding, font size, font color, font inclination, underlining, superscript and subscript; the case history editor module also supports the insertion of pictures, formulas and special symbol shortcuts.
Further, the medical record storage module is in communication connection with the cloud server.
Further, the medical record storage module comprises five formats of input and output of html, json, txt, xml and structured node information.
Furthermore, the electronic medical record editor also comprises a quality control module in communication connection with the medical record editing module, and the quality control module displays, hides and changes values of components in the medical record editing module through quality control rules; the quality control rule comprises data operation, hiding, displaying and bidirectional binding, wherein:
1) the operation means that the associated components and the associated components are selected from the medical record editing module, and then the operation rule preset in the quality control module is called to enable the associated components and the associated components to operate, so that the associated component values are changed;
2) the hiding and displaying means that related components and related components are selected from the medical record editing module, and then the preset displaying or hiding conditions in the quality control module are called to judge whether the relationship between the related components and the related components meets the displaying or hiding conditions, so that the displaying and hiding of the related components are realized;
3) the bidirectional binding is to perform bidirectional control on the associated component and the associated component through an operation, display or hiding rule, so that the operation, display or hiding of the associated component can be realized, the operation, display or hiding of the associated component can also be realized, and the quality control of the medical record editing module on the medical record component is realized.
Furthermore, the medical record editing module is also provided with a communication interface which is used for being in communication connection with a third-party medical record system and quickly inserting text contents in the third-party medical record system into the electronic medical record.
In order to solve the above technical problem, the present invention further provides a method for implementing an electronic medical record editor based on a BS architecture, comprising the following steps:
s1: storing data elements corresponding to the illness state in a node storage module in advance; the node storage module stores a data set consisting of the data elements and the data elements as component basic data in the medical record component module;
s2: in the design mode, components in the medical record component module are called through the medical record editing module, and small templates in the small template module are called to generate an electronic medical record template, so that the design of the electronic medical record template is realized; then, the edited electronic medical record template is transmitted to a template storage module for storage;
s3: when the electronic medical record is required to be edited, the text information related to the illness state is input to realize the online editing of the electronic medical record directly by calling the electronic medical record template designed in the template storage module; and then storing the edited electronic medical record in a medical record storage module.
Furthermore, a quality control rule is preset in the quality control module, and the medical record editing module calls the quality control rule in the quality control module to perform component quality control according to an electronic medical record text written by a doctor.
Compared with the prior art, the invention has the beneficial effects that: the method comprises the following steps that three working modes are adopted, components in a medical record component module are called through a medical record editing module and small templates in a small template module are called to generate an electronic medical record template in a design mode, the design of the electronic medical record template is realized, and the edited electronic medical record template is transmitted to a template storage module to be stored; under the read-write mode, the text information related to the illness state is input directly by calling the electronic medical record template designed in the template storage module, so that the electronic medical record is edited on line, the edited electronic medical record is stored in the medical record storage module, the operation flow is simplified, and the problems of unsatisfied functions, poor structuralization and complex use of the conventional electronic medical record editor are solved.
Drawings
Fig. 1 is a schematic structural diagram of an electronic medical record editor based on a BS architecture in embodiment 1 and embodiment 2;
FIG. 2 is a schematic diagram showing the composition of an electronic medical record according to example 1 and example 2;
wherein, 1, a medical record editing module; 2. a small template module; 3. a medical record component module; 4. a node storage module; 5. a medical record storage module; 6. a template storage module; 7. a medical record printing module; 8. a cloud server; 9. and a quality control module.
Detailed Description
In order to make the objects, technical solutions and advantages of the present invention more apparent, the present invention is further described in detail below with reference to examples and accompanying drawings, and the exemplary embodiments and descriptions thereof are only used for explaining the present invention and are not meant to limit the present invention.
Example 1:
referring to fig. 1 and 2, an electronic medical record editor based on a BS architecture includes a medical record editing module 1, a small template module 2, a medical record component module 3, a node storage module 4, a medical record storage module 5 and a template storage module 6, wherein the small template module 2, the medical record component module 3, the medical record storage module 5 and the template storage module 6 are all in communication connection with the medical record editing module 1; the small template module 2 and the node storage module 4 are in communication connection with the medical record component module 3;
the node storage module 4 is used for providing basic data of the medical record template component to the medical record component module 3, wherein the basic data of the component comprises a data element corresponding to the disease condition, a data set consisting of a plurality of data elements and a value range of the data element;
the medical record component module 3 is used for forming and storing the basic data of the medical record template transmitted by the node storage module 4 into components;
the small template module 2 is used for providing an electronic medical record small template for the medical record editing module 1; the small template mainly comprises components and texts, wherein the texts with high use frequency and the corresponding components are extracted to be independently manufactured into the small template which is stored in the small template module 2;
the medical record editing module 1 comprises three working modes, namely a design mode, a read-write mode and a read-only mode;
the medical record editing module 1 is used for calling medical record components in the medical record component module 3 and inputting corresponding texts in the design mode, and can also call and quote small templates in the small template module 2, add the medical record components and the small templates into the medical record templates, and then transmit the edited medical record templates to the template storage module 6 for storage;
the medical record editing module 1 is used for inputting a text related to a medical record into the medical record template in the read-write mode and storing the edited electronic medical record into the medical record storage module 5;
the medical record editor can directly display the edited medical record template in the read-only mode;
the electronic medical record editor also comprises a medical record printing module 7, the medical record printing module 7 is in communication connection with the medical record editor, and the medical record editing module 1 can print the edited electronic medical record through the medical record printing module 7.
An electronic medical record can be split into texts, components and small templates (such as figure 2); the text is any character written by a doctor and is used for describing relevant information of the patient, including information of the identity information of the patient, the name and the type of the patient, detection data and indexes, a treatment scheme and the like. The components comprise an input box, a drop-down box, a radio box, a multi-selection box and the like, so that the quick input by a doctor is facilitated, and important node information is structurally stored. The small template consists of texts and components, which is equivalent to extracting a section of content for independent processing; when the patient is in writing, a doctor writes a plurality of medical records on one patient, the medical records have the same content, the content is extracted and stored by using the small template, the content can be stored in the small template module 2 after the first medical record is written, when the patient is in writing other diseases, if the small template needs to be called correspondingly in the first medical record, the small template is inserted in a quoted mode when the template is manufactured, and the content can be automatically brought into the medical records during writing.
In this embodiment, a method for manufacturing an electronic medical record includes: data elements corresponding to the illness state are stored in the node storage module 4 in advance, and a small template is stored in the small template module 2; the node storage module 4 stores a data set consisting of data elements and a plurality of data elements as component basic data in the medical record component module 3; when a medical record template is required to be designed, a design mode of an editing module is started, components in a medical record component module 3 are called through a medical record editing module 1, and a small template in a small template module 2 is called to generate an electronic medical record template, so that the design of the electronic medical record template is realized; then, the edited electronic medical record template is transmitted to the template storage module 6 for storage; when the electronic medical record is required to be edited, the text information related to the illness state is input directly through calling the electronic medical record template designed in the template storage module 6 to realize the online editing of the electronic medical record; and then the edited electronic medical record is stored in the medical record storage module 5.
The medical record editing module 1 in this embodiment also supports setting of styles for text contents, including bolding, font size, font color, font tilt, underlining, superscript, and subscript; the medical record editor module also supports the insertion of pictures, formulas and special symbol shortcut keys to meet different requirements.
The medical record storage module 5 in this embodiment is connected to the cloud server 8 in a communication manner, and the medical record storage module 5 includes inputs and outputs in five formats, i.e., html, json, txt, xml and structured node information. BS mode construction is carried out on the electronic medical record editors of all hospitals, namely a browser and cloud server 8 framework mode; the medical record storage module 5 can transmit the patient medical record data to the cloud server 8 in the format of html, json, txt, xml and structured node information, or the cloud server 8 directly reads the patient medical record data in the medical record storage module 5 after authorization and forms a database in the cloud server 8; the browser performs data interaction with the database through the WebServer, each hospital sends a data request to the cloud server 8 through the browser terminal, and the cloud server 8 transmits relevant information in the patient medical record database to the browser for medical staff to browse and check; seamless connection of the patient electronic medical record data and other hospital information systems and cross-platform operation are achieved. In addition, the browser can directly access the electronic medical record editor through the cloud server 8, and directly read data information in the medical record storage module 5.
In addition, the medical record editing module 1 is further provided with a communication interface, the communication interface is used for being in communication connection with a third-party medical record system, and text contents in the third-party medical record system are quickly inserted into an electronic medical record, such as doctor advice, examination, inspection, operation and other information. The automatic reading and transferring of the medical record information of the corresponding patient in the third-party medical record system by the medical record editing module are realized, and the medical record information can be directly displayed in the electronic medical record generated by the electronic medical record editor.
The electronic medical record editor also comprises a quality control module 9 in communication connection with the medical record editing module 1, wherein the quality control module 9 displays, hides and changes values of components in the medical record editing module 1 through quality control rules, so that the medical record editing module 1 can perform quality control on medical record components; the quality control rule comprises data operation, hiding, displaying and bidirectional binding, wherein:
1) the operation refers to selecting the components needing to be bound and the associated components from the medical record editing module 1, and then calling the operation rules (sum, difference, average value and the like) preset in the quality control module 9 to enable the associated components and the associated components to carry out operation such as summation, difference or average value and the like, so as to realize the change of the associated component values;
2) the hiding and displaying means that the related components and the related components are selected from the medical record editing module 1, and then the displaying or hiding conditions (equal to, greater than, less than, fuzzy matching and the like) preset in the quality control module 9 are called to judge whether the relations of equal to, greater than, less than, fuzzy matching and the like between the related components and the related components meet the displaying or hiding conditions, so that the displaying and hiding of the related components are realized;
3) the bidirectional binding is to perform bidirectional control on the associated component and the associated component through an operation, display or hiding rule, so that the operation, display or hiding of the associated component can be realized, and the operation, display or hiding of the associated component can also be realized.
Example 2:
referring to fig. 1 and 2, an implementation method of an electronic medical record editor based on a BS architecture includes the following steps:
s1: data elements corresponding to the illness state are stored in the node storage module 4 in advance; the node storage module 4 stores a data set consisting of data elements and a plurality of data elements as component basic data in the medical record component module 3;
s2: in the design mode, components in the medical record component module 3 are called through the medical record editing module 1, and small templates in the small template module 2 are called to generate an electronic medical record template, so that the design of the electronic medical record template is realized; then, the edited electronic medical record template is transmitted to the template storage module 6 for storage;
s3: when the electronic medical record is required to be edited, the text information related to the illness state is input directly through calling the electronic medical record template designed in the template storage module 6 to realize the online editing of the electronic medical record; and then the edited electronic medical record is stored in the medical record storage module 5. The medical record component module in the embodiment also provides a special linkage component to support linkage prompt input content. Such as two drop-down box components, the content selected by the first drop-down box may affect the content selected by the second drop-down box.
Meanwhile, under the design mode of the medical record editing module, the creation of the electronic medical record template supports a plurality of dynamic associated electronic medical record templates, and after one electronic medical record template is selected, other electronic medical record templates associated with the selected electronic medical record template can be automatically displayed. When the electronic medical record is written in the read-write mode, the corresponding components or text contents in the associated electronic medical record template can be automatically established according to the set associated electronic medical record template.
Quality control rules are preset in the quality control module 9, and the medical record editing module 1 calls the quality control rules in the quality control module 9 to perform component quality control according to electronic medical record texts written by doctors. The quality control rule comprises data operation, hiding, displaying and bidirectional binding, wherein:
1) the operation refers to selecting the components needing to be bound and the associated components from the medical record editing module 1, and then calling the operation rules (sum, difference, average value and the like) preset in the quality control module 9 to enable the associated components and the associated components to carry out operation such as summation, difference or average value and the like, so as to realize the change of the associated component values;
2) the hiding and displaying means that the related components and the related components are selected from the medical record editing module 1, and then the displaying or hiding conditions (equal to, greater than, less than, fuzzy matching and the like) preset in the quality control module 9 are called to judge whether the relations of equal to, greater than, less than, fuzzy matching and the like between the related components and the related components meet the displaying or hiding conditions, so that the displaying and hiding of the related components are realized;
3) the bidirectional binding is to perform bidirectional control on the associated component and the associated component through an operation, display or hiding rule, so that the operation, display or hiding of the associated component can be realized, and the operation, display or hiding of the associated component can also be realized.
The above is an embodiment of the present invention. The embodiments and specific parameters in the embodiments are only for the purpose of clearly illustrating the verification process of the invention and are not intended to limit the scope of the invention, which is defined by the claims, and all equivalent structural changes made by using the contents of the specification and the drawings of the present invention should be covered by the scope of the present invention.
Claims (8)
1. An electronic medical record editor based on BS architecture is characterized in that: the medical record editing system comprises a medical record editing module (1), a small template module (2), a medical record component module (3), a node storage module (4), a medical record storage module (5) and a template storage module (6), wherein the small template module (2), the medical record component module (3), the medical record storage module (5) and the template storage module (6) are all in communication connection with the medical record editing module (1); the small template module (2) and the node storage module (4) are in communication connection with the medical record component module (3);
the node storage module (4) is used for providing basic data of the medical record template component to the medical record component module (3), and the basic data of the component comprises a data element corresponding to the disease condition, a data set consisting of a plurality of data elements and a value range of the data element;
the medical record component module (3) is used for forming a component for the medical record template basic data transmitted by the node storage module (4) and storing the component;
the small template module (2) is used for providing an electronic medical record small template for the medical record editing module (1); the small template mainly comprises components and texts, and is characterized in that the texts with high use frequency and the corresponding components thereof are extracted and independently made into small templates which are stored in the small template module (2);
the medical record editing module (1) comprises three working modes, namely a design mode, a read-write mode and a read-only mode;
the medical record editing module (1) is used for calling medical record components in the medical record component module (3) and inputting corresponding texts in the design mode, and also can call and quote small templates in the small template module (2), add the medical record components and the small templates into the medical record templates, and then transmit the edited medical record templates to the template storage module (6) for storage;
the medical record editing module (1) is used for inputting medical record related texts into the medical record template in the read-write mode and storing the edited electronic medical record into the medical record storage module (5);
the medical record editor can directly display the edited medical record template in the read-only mode;
the electronic medical record editor also comprises a medical record printing module (7), the medical record printing module (7) is in communication connection with the medical record editor, and the medical record editing module (1) can print the edited electronic medical record through the medical record printing module (7).
2. The BS architecture-based electronic medical record editor of claim 1, wherein: the medical record editing module (1) also supports setting styles of text contents, including bolding, font size, font color, font inclination, underlining, superscript and subscript; the case history editor module also supports the insertion of pictures, formulas and special symbol shortcuts.
3. The BS architecture-based electronic medical record editor of claim 1, wherein: the medical record storage module (5) is in communication connection with the cloud server (8).
4. The BS architecture-based electronic medical record editor of claim 3, wherein: the medical record storage module (5) comprises five formats of input and output of html, json, txt, xml and structured node information.
5. The BS architecture-based electronic medical record editor of claim 1, wherein: the electronic medical record editor also comprises a quality control module (9) in communication connection with the medical record editing module (1), wherein the quality control module (9) displays, hides and changes values of components in the medical record editing module (1) through quality control rules; the quality control rule comprises data operation, hiding, displaying and bidirectional binding, wherein:
1) the operation refers to selecting the components needing to be bound and the associated components from the medical record editing module (1), and calling the operation rule preset in the quality control module (9) to operate the associated components and the associated components, so as to realize the change of the associated component values;
2) hiding and displaying means that related components and related components are selected from the medical record editing module (1), and then a preset displaying or hiding condition in the quality control module (9) is called to judge whether the relationship between the related components and the related components meets the displaying or hiding condition, so that the displaying and hiding of the related components are realized;
3) the bidirectional binding is to perform bidirectional control on the associated component and the associated component through an operation, display or hiding rule, so that the operation, display or hiding of the associated component can be realized, and the operation, display or hiding of the associated component can also be realized.
6. The BS architecture-based electronic medical record editor of claim 1, wherein: the medical record editing module is also provided with a communication interface which is used for being in communication connection with a third-party medical record system and quickly inserting text contents in the third-party medical record system into the electronic medical record.
7. A method for implementing an electronic medical record editor based on BS architecture, the method being based on the electronic medical record editor based on BS architecture of any one of claims 1-6, comprising the following steps:
s1: data elements corresponding to the illness state are stored in the node storage module (4) in advance; the node storage module (4) stores a data set consisting of the data elements and the data elements as component basic data in the medical record component module (3);
s2: in the design mode, components in the medical record component module (3) are called through the medical record editing module (1), and small templates in the small template module (2) are called to generate an electronic medical record template, so that the design of the electronic medical record template is realized; then, the edited electronic medical record template is transmitted to a template storage module (6) for storage;
s3: when the electronic medical record is required to be edited, the text information related to the illness state is input directly through calling the electronic medical record template designed in the template storage module (6) to realize the online editing of the electronic medical record; and then the edited electronic medical record is stored in a medical record storage module (5).
8. The method for implementing an electronic medical record editor based on BS architecture as claimed in claim 7, wherein: quality control rules are preset in the quality control module (9), and the medical record editing module (1) calls the quality control rules in the quality control module (9) to perform component quality control according to electronic medical record texts written by doctors.
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| CN111311461A (en) * | 2020-03-27 | 2020-06-19 | 北京尚医智信健康管理有限公司 | B-S based editor and generation method for structured dynamic medical record form |
| CN111488730A (en) * | 2020-04-02 | 2020-08-04 | 重庆橡树信息科技有限公司 | Editor-based automatic generation method for single-disease electronic medical record |
| CN111540431A (en) * | 2020-04-26 | 2020-08-14 | 常州市第二人民医院 | Electronic medical record template configuration system based on standard database |
| CN111540430A (en) * | 2020-04-26 | 2020-08-14 | 常州市第二人民医院 | Electronic medical record standardized printing system |
| CN112560424A (en) * | 2020-12-23 | 2021-03-26 | 江苏达实久信数字医疗科技有限公司 | Form generation method, device and system suitable for hospital operation electronic medical record |
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