CN111145915A - Health care follow-up visit and medical record management system for children - Google Patents

Health care follow-up visit and medical record management system for children Download PDF

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CN111145915A
CN111145915A CN201911416479.6A CN201911416479A CN111145915A CN 111145915 A CN111145915 A CN 111145915A CN 201911416479 A CN201911416479 A CN 201911416479A CN 111145915 A CN111145915 A CN 111145915A
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medical record
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程茜
吴万春
王娟
蒋志阳
刘正春
李文军
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Chongqing Yue Yi Tong Technology Co ltd
Childrens Hospital of Chongqing Medical University
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Chongqing Yue Yi Tong Technology Co ltd
Childrens Hospital of Chongqing Medical University
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    • GPHYSICS
    • G16INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16HHEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H10/00ICT specially adapted for the handling or processing of patient-related medical or healthcare data
    • G16H10/60ICT specially adapted for the handling or processing of patient-related medical or healthcare data for patient-specific data, e.g. for electronic patient records
    • GPHYSICS
    • G06COMPUTING; CALCULATING OR COUNTING
    • G06FELECTRIC DIGITAL DATA PROCESSING
    • G06F16/00Information retrieval; Database structures therefor; File system structures therefor
    • G06F16/30Information retrieval; Database structures therefor; File system structures therefor of unstructured textual data
    • G06F16/33Querying
    • G06F16/335Filtering based on additional data, e.g. user or group profiles
    • GPHYSICS
    • G16INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16HHEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H50/00ICT specially adapted for medical diagnosis, medical simulation or medical data mining; ICT specially adapted for detecting, monitoring or modelling epidemics or pandemics
    • G16H50/70ICT specially adapted for medical diagnosis, medical simulation or medical data mining; ICT specially adapted for detecting, monitoring or modelling epidemics or pandemics for mining of medical data, e.g. analysing previous cases of other patients

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  • Physics & Mathematics (AREA)
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Abstract

The invention relates to the technical field of child medical care management, and provides a child health care follow-up and medical record management system which aims at solving the problem that the retrieval efficiency of medical records is not high because a preset medical record module is not targeted in the existing medical record management system, wherein the system comprises a database and a database, wherein a blank medical record template is prestored; the acquisition module is used for acquiring basic sign data and retrieving keywords; the recording module is used for recording the basic physical sign data into the medical record template and generating the medical record; the retrieval module is used for retrieving and outputting the corresponding medical records from the database; a marking rule is prestored in the database; the marking module is used for marking the medical records stored in the database; the self-defining module is used for receiving the self-defining information, carrying out self-defining editing on the marked medical records to generate a special case and further generating a special case label, and the retrieval module is also used for searching and outputting the special case according to the special case label and the retrieval key words. The invention can improve the retrieval efficiency of medical records.

Description

Health care follow-up visit and medical record management system for children
Technical Field
The invention relates to the technical field of child medical care management, in particular to a child health care follow-up visit and medical record management system.
Background
The medical staff records the occurrence, development and outcome of the disease of the patient in the process of medical activities such as examination, diagnosis and treatment, and the medical health file of the patient obtained after induction and arrangement is the medical record. With the development of science and technology, most hospitals adopt a medical record management system to carry out intelligent management on medical records at present. However, in the existing medical record management system, the established medical record is usually stored in the system only after the medical record of the relevant patient is established according to the acquired data, and when a doctor needs to retrieve the medical record of a certain patient, the doctor can retrieve the relevant medical record stored in the system through a searching function. Compared with the traditional paper medical records, the medical record management system improves the retrieval efficiency of the medical records.
Because the prior medical record management system fills the collected data into the medical record template preset by the system when establishing the medical record of the patient, the preset medical record template needs to relate to a plurality of different aspects in order to meet the requirements of most diseases on the medical record, and thus, no pertinence exists. Therefore, as the number of medical records stored in the system is increased continuously, when the medical records are searched according to the keywords, a plurality of medical records related to the keywords can be searched, and the corresponding medical records to be searched can be searched after the cases are browsed, so that the searching efficiency of the medical records is reduced, and the centralized management of the medical records is inconvenient.
Disclosure of Invention
The invention aims to provide a child health care follow-up visit and medical record management system to solve the problem that the current medical record management system is low in the retrieval efficiency of medical records due to the fact that a preset medical record module is not targeted.
The basic scheme provided by the invention is as follows: the child health care follow-up visit and medical record management system comprises a database, wherein a blank medical record template is prestored;
the acquisition module is used for acquiring basic sign data; the system is also used for collecting retrieval keywords;
the recording module is used for recording the acquired basic physical sign data into a blank medical record template and generating a medical record of the patient, and the database stores the medical record;
the retrieval module is used for retrieving and outputting corresponding medical records from the database according to the retrieval keywords;
wherein: a marking rule is prestored in the database;
the marking module is used for marking the medical records stored in the database according to the marking rules;
the self-defining module is used for receiving the self-defining information, carrying out self-defining editing on the marked medical records to generate a special case, generating a special case label according to the special case, storing the special case and the special case label in a database in a correlation mode, and searching the special case according to the special case label and the search key words and outputting the searched special case.
The basic scheme has the working principle and the beneficial effects that: compared with the existing management system, in the scheme, through the matching of the marking rule, the marking module and the custom module, the marking module is used for marking the medical records which accord with the marking rule, then the custom module carries out custom editing on the marked medical records according to custom information to generate a special case, and the special case is also associated with the special disease label and stored in the database, on one hand, the special case is generated by carrying out custom editing according to the custom information, so that the medical cases can be correspondingly modified through the custom information according to actual conditions, further detailed recording and storage can be carried out on some physical sign data which need to be recorded in a key way to obtain the special case, and when the special case is viewed, the key points can be clearly seen; on the other hand, the special case label is generated according to the special case, so that the search is carried out according to the special case label and the search keyword during the search, compared with the search keyword which is directly adopted, the searched medical case is more accurate, and the retrieval efficiency of the medical case is improved.
The first preferred scheme is as follows: preferably, the basic scheme further comprises an analysis module for analyzing the stored project to generate a special disease analysis template. Description of the drawings: the special disease analysis module in the scheme comprises four parts of initial diagnosis, differential diagnosis, further examination and treatment principle.
Has the advantages that: in this scheme, carry out the analysis to the special case through setting up analysis module to obtain special illness analysis template, the doctor can have more detailed understanding to this kind of state of an illness through special illness analysis module, thereby effectively knows the emergence and the treatment scheme of special illness, improves the diagnosis and treatment efficiency to this special illness.
The preferred scheme II is as follows: preferably, when the database stores the special cases, the special cases are classified and stored according to the corresponding special disease labels. Has the advantages that: in the scheme, the special cases are classified and stored, so that the special cases can be managed in a targeted manner.
The preferable scheme is three: preferably, the second preferred scheme further comprises a statistics module for performing statistics on the project of each special disease label stored in the database to obtain a special disease statistic value, and the database is further used for storing the special disease statistic value in association with the corresponding special disease label. Has the advantages that: in the scheme, the special disease statistic obtained through statistics also indicates the occurrence frequency of the special disease, so that a doctor can conveniently and timely master the spreading condition of the special disease.
The preferable scheme is four: as the optimization of the basic scheme, the system also comprises a follow-up reminding module which is used for sending follow-up reminding information to the patient and the corresponding doctor. Has the advantages that: the follow-up refers to an observation method for the hospital to regularly know the disease condition change of the patient and guide the patient to recover by communication or other means with the patient who has been in a visit in the hospital. In the scheme, the follow-up visit reminding module is arranged to automatically remind a doctor to follow-up visit, so that the doctor can track and observe the illness state or the rehabilitation condition of the patient conveniently, and the smooth rehabilitation of the patient is guaranteed.
The preferable scheme is five: preferably, the system further comprises a timing module, the follow-up visit period is prestored in the database, when the medical records are stored in the database, the timing module starts timing and generates timing information of the corresponding medical records, and when the timing information is equal to the follow-up visit period, the follow-up visit reminding module sends follow-up visit reminding information. Has the advantages that: in the scheme, the follow-up periodic reminding is realized through the setting of the timing module, and the operation is simple.
The preferable scheme is six: the second preferred scheme further comprises a screening module, the database is also pre-stored with screening conditions, the screening module is used for screening the medical records and the special cases stored in the database according to the screening conditions, the statistical module is also used for counting the screened medical records and the special cases and generating corresponding screening statistical values, and the database stores the screening conditions and the corresponding screening statistical values in an associated manner. Has the advantages that: in this scheme, realize the screening and generate the screening statistics to all medical records of storage through the cooperation of screening module and statistics module, the doctor can directly know the patient's number of people who satisfies the screening condition according to this screening statistics to in time know the severity of corresponding disease, and in time prevent the emergence of some epidemic diseases, do the work of disease prevention and control.
The preferable scheme is seven: preferably, the second preferred scheme further comprises an alarm module, the database is also prestored with a statistical threshold value, and when the special disease statistic value is greater than the statistical threshold value, the alarm module sends special disease alarm information. Has the advantages that: in this scheme, through setting up the statistics threshold value, when the special illness statistics value is greater than the statistics threshold value, show that this moment this special illness's patient number of people has surpassed a definite value, need in time prevent and treat, warning module sends special illness warning information this moment to remind the doctor in time to this special illness to launch prevention and control work.
The preferable scheme is eight: as the optimization of the basic scheme, the system also comprises a pushing module used for pushing the marked medical records. Has the advantages that: in this scheme, just carry out the propelling movement by the propelling movement module after the medical record is marked, so, the doctor can in time know the condition of corresponding special illness to in time diagnose and treat.
The preferable scheme is nine: preferably, the system further comprises a matching module, the database further comprises a pushing tag, the matching module is used for matching the marked medical records with the pushing tag, and the pushing module pushes the medical records when the marked medical records are matched with the pushing tag. Has the advantages that: considering that the condition of the disease condition of some marked medical records is not serious, if pushing is carried out at the moment, the normal work of a doctor can be influenced, and therefore the matching module is further arranged in the scheme, the pushing module can carry out pushing only under the condition that the marked medical records are matched with the pushing labels, and therefore invalid pushing operation can be avoided.
Drawings
FIG. 1 is a block diagram of a child care follow-up and medical record management system according to an embodiment of the present invention;
FIG. 2 is a schematic diagram of a medical record generated based on the basic vital sign data;
FIG. 3 is a schematic diagram of the generated disease-specific protocol;
FIG. 4 is a schematic diagram of screening when screening is performed;
fig. 5 is a statistical diagram after statistics according to regions.
Detailed Description
The following is further detailed by way of specific embodiments:
example one
Substantially as shown in figure 1: the child health care follow-up visit and medical record management system comprises a database, wherein a follow-up visit period, a screening condition, a statistical threshold value, a push label and a blank medical record template are prestored;
the acquisition module is used for acquiring basic sign data and retrieving keywords;
the recording module is used for recording the acquired basic physical sign data into a blank medical record template and generating a medical record of the patient, and the database stores the medical record;
the retrieval module is used for retrieving and outputting corresponding medical records from the database according to the retrieval keywords;
wherein: a marking rule is prestored in the database;
the marking module is used for marking the medical records stored in the database according to the marking rules;
the self-defining module is used for receiving self-defining information, self-defining and editing the marked medical records to generate a special case, generating a special case label according to the special case, storing the special case and the special case label in a database in a correlation mode, classifying and storing the special case according to the corresponding special case label, and searching and outputting the special case according to the special case label and the search key word;
the analysis module is used for analyzing the stored special case to generate a special disease analysis template;
the statistical module is used for carrying out statistics on the project of each special disease label stored in the database to obtain a special disease statistical value, and the database is also used for carrying out correlation storage on the special disease statistical value and the corresponding special disease label;
the screening module is used for screening the medical records and the special cases stored in the database according to the screening conditions, the counting module is also used for counting the screened medical records and the special cases and generating corresponding screening statistical values, and the database stores the screening conditions and the corresponding screening statistical values in an associated mode;
the warning module sends special disease warning information when the special disease statistic value is larger than the statistic threshold value;
the matching module is used for matching the marked medical records with the push labels;
and the pushing module is used for pushing the marked medical records when the marked medical records are matched with the pushing labels.
The specific implementation process is as follows: during the use, the collection module gathers patient's basic sign data, and the collection module can be the keyboard for example, and the doctor passes through the keyboard and inputs patient's basic sign data to the system, accomplishes the collection operation of basic sign data.
After the basic physical sign data is acquired, the recording module records the acquired basic physical sign data into a blank medical record template, and then generates a medical record of the patient, as shown in fig. 2.
When a doctor needs to call the medical record of a certain patient, the acquisition module acquires the retrieval key words, if the doctor wants to call the medical record of the patient A, the retrieval key words 'patient A' are acquired at the moment, and the retrieval module retrieves all the medical records of the patient A from the database for the doctor to look up.
The database is also provided with marking rules, and the marking module marks the medical records according to the pre-stored marking rules. The marking rule is set as body weight index > X, and the body weight index calculation formula is set as body weight (kg) ÷ height squared (m). Assuming that the body mass index of patient B is greater than X, the marking module marks the medical record.
Taking the obese project as an example, after the marking module marks the medical project with the body mass index greater than X, the custom module receives custom information, generates the project after the marked medical project is marked by the custom, and generates a special disease label of 'obese children special disease', as shown in fig. 3. And then the database classifies and stores the special cases according to the corresponding special disease labels.
After the project is stored in the database, the analysis module analyzes the stored project to obtain a project analysis template, and specifically, the project analysis module comprises four parts, namely, a primary diagnosis part, a differential diagnosis part, a further examination part and a treatment principle part, which are shown in the table I.
Watch 1
Preliminary diagnosis Differential diagnosis Further inspection Principle of treatment
Obesity Symptom
1, symptom 2, and symptom 3 Inspection item 1 and inspection item 2 Treatment 1, treatment 2
The statistic module is used for carrying out statistics on the special case according to each special disease label to obtain a special disease statistic value, and the database is used for storing the statistic special disease statistic value and the corresponding special disease label in a correlation mode.
When the condition of a patient with a certain type of specific disease needs to be checked, the screening module is used for screening the medical records and the specific records stored in the database according to the screening conditions, and as shown in fig. 4, the screening can be performed by selecting the corresponding specific disease label. After the screening is completed, the statistics module also generates corresponding screening statistics, as shown in fig. 5. And when the special disease statistic value is larger than the statistical threshold value, the warning module sends special disease warning information, the statistical threshold value of the obese child special disease is set to be Y, the statistical module counts the special disease statistic value of the obese child to be F, and when the F is larger than Y, the warning module sends the obese child special disease warning information.
And setting the pre-stored push label in the database as 'body mass index > X1', wherein X1 > X. The existing body mass index of the patient C is X3, when X < X3 < X1, the medical record of the patient is marked but not pushed, and when X3 > X1, the pushing module pushes the medical record of the patient C to a doctor.
Example two
The difference from the first embodiment is that the embodiment further comprises a timing module, and when the database stores the medical records, the timing module starts timing and generates timing information of the corresponding medical records;
and the follow-up visit reminding module is used for sending follow-up visit reminding information to the patient and the corresponding doctor when the timing information is equal to the follow-up visit period.
In this embodiment, realize reminding the doctor to follow up the visit automatically through the cooperation that sets up timing module and follow-up visit and remind the module, the doctor of being convenient for trails the observation to the state of an illness or the recovered condition of patient to guarantee patient's recovery smoothly.
EXAMPLE III
The difference between the first embodiment and the second embodiment is that the system further comprises a patient terminal, and the patient terminal comprises a receiving module for receiving follow-up visit reminding information;
the storage module is used for storing follow-up visit reminding information, and also prestores a voiceprint library, scene determination rules and display rules, wherein the voiceprint library comprises a plurality of standard voiceprints including palm voiceprints, music voiceprints, preset person speaking voiceprints, other task speaking voiceprints and the like;
the environment acquisition module is used for acquiring sound information of the surrounding environment;
the processing module is used for processing the collected sound information and obtaining an environmental voiceprint;
the matching module is used for matching the processed environmental voiceprint with the standard voiceprint to obtain a corresponding standard voiceprint;
the recognition module is used for determining a rule according to the matched standard voiceprint and scene to recognize the current environment scene;
and the display module is used for displaying the received follow-up visit reminding information according to a preset display rule.
The pre-stored scene determination rules are shown in table two.
Watch two
Figure BDA0002351324000000061
Figure BDA0002351324000000071
The preset display rules are shown in table three.
Watch III
Scene Displaying time
Public place scene Immediate display
Meeting scene Postponement of display
Important character conversation scenario Postponement of display
Recreation and entertainment scene Immediate display
As shown in table two and table three, if the matching module matches that the current surrounding environment has a plurality of voices, that is, when a plurality of other persons speak voiceprints, the current patient is determined to be in a public place, such as on a bus, on a street, etc., and the patient can view the information at any time without any influence, so that the display module immediately displays the information when receiving the follow-up visit reminding information; if the preset person is matched to speak, if the preset person is a company boss, the patient is determined to be in an important person conversation scene at the moment, if the follow-up reminding information is displayed by the display module at the moment, the current conversation is influenced or interrupted, and adverse effects are caused, so that the follow-up reminding information is delayed to be displayed by the display module at the moment, and the follow-up reminding information can be displayed immediately when the follow-up reminding information is matched by the matching module at the current scene; therefore, the follow-up visit reminding information can be normally sent to the patient terminal, and meanwhile, the normal work or life of the patient cannot be influenced.
The foregoing are merely exemplary embodiments of the present invention, and no attempt is made to show structural details of the invention in more detail than is necessary for the fundamental understanding of the art, the description taken with the drawings making apparent to those skilled in the art how the several forms of the invention may be embodied in practice with the teachings of the invention. It should be noted that, for those skilled in the art, without departing from the structure of the present invention, several changes and modifications can be made, which should also be regarded as the protection scope of the present invention, and these will not affect the effect of the implementation of the present invention and the practicability of the patent. The scope of the claims of the present application shall be determined by the contents of the claims, and the description of the embodiments and the like in the specification shall be used to explain the contents of the claims.

Claims (10)

1. The child health care follow-up visit and medical record management system comprises a database, wherein a blank medical record template is prestored;
the acquisition module is used for acquiring basic sign data and retrieving keywords;
the recording module is used for recording the acquired basic physical sign data into a blank medical record template and generating a medical record of the patient, and the database stores the medical record;
the retrieval module is used for retrieving and outputting corresponding medical records from a database according to the retrieval keywords;
the method is characterized in that: a marking rule is prestored in the database;
the marking module is used for marking the medical records stored in the database according to the marking rules;
the self-defining module is used for receiving self-defining information, carrying out self-defining editing on the marked medical records to generate a special case, generating a special case label according to the special case, storing the special case and the special case label in a related mode through the database, and searching the special case according to the special case label and the search key words and outputting the searched special case.
2. The child healthcare follow-up and medical record management system as claimed in claim 1, wherein: the system also comprises an analysis module which is used for analyzing the stored special case to generate a special disease analysis template.
3. The child healthcare follow-up and medical record management system as claimed in claim 1, wherein: and when storing the special cases, the database stores the special cases in a classified manner according to the corresponding special disease labels.
4. The child healthcare follow-up and medical record management system as claimed in claim 3, wherein: the system also comprises a statistic module used for carrying out statistics on the project of each special disease label stored in the database to obtain a special disease statistic value, and the database is also used for carrying out association storage on the special disease statistic value and the corresponding special disease label.
5. The child healthcare follow-up and medical record management system as claimed in claim 1, wherein: the follow-up visit reminding module is used for sending follow-up visit reminding information to the patient and the corresponding doctor.
6. The child healthcare follow-up and medical record management system as claimed in claim 5, wherein: the system comprises a database, and is characterized by further comprising a timing module, wherein a follow-up visit period is prestored in the database, when a medical record is stored in the database, the timing module starts timing and generates timing information of the corresponding medical record, and when the timing information is equal to the follow-up visit period, the follow-up visit reminding module sends follow-up visit reminding information.
7. The child healthcare follow-up and medical record management system as claimed in claim 3, wherein: still including the screening module, the database has the screening condition in advance still, the screening module is used for the basis the screening condition is right the medical record and the special case that store in the database are filtered, the statistics module still is used for making statistics of the medical record and the special case of screening out and generates corresponding screening statistics, the database is relevant to be stored screening condition and corresponding screening statistics.
8. The child healthcare follow-up and medical record management system as claimed in claim 3, wherein: the special illness state monitoring system is characterized by further comprising a warning module, wherein a statistic threshold value is prestored in the database, and when the special illness state statistic value is larger than the statistic threshold value, the warning module sends special illness warning information.
9. The child healthcare follow-up and medical record management system as claimed in claim 1, wherein: the medical record marking system further comprises a pushing module used for pushing the marked medical record.
10. The child care follow-up and medical record management system as claimed in claim 9, wherein: the database comprises a database body, and is characterized by further comprising a matching module, wherein the database further comprises a pushing label, the matching module is used for matching the marked medical records with the pushing label, and when the marked medical records are matched with the pushing label, the pushing module pushes the medical records.
CN201911416479.6A 2019-12-31 2019-12-31 Health care follow-up visit and medical record management system for children Pending CN111145915A (en)

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Application publication date: 20200512