CN111292817A - Electronic medical record generation method and device - Google Patents
Electronic medical record generation method and device Download PDFInfo
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- CN111292817A CN111292817A CN201811493965.3A CN201811493965A CN111292817A CN 111292817 A CN111292817 A CN 111292817A CN 201811493965 A CN201811493965 A CN 201811493965A CN 111292817 A CN111292817 A CN 111292817A
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Abstract
The embodiment of the invention is suitable for the technical field of medical record management, and provides a method and a device for generating an electronic medical record, wherein the method comprises the following steps: determining basic information of a current patient and a medical record template to be used, wherein the medical record template comprises a plurality of basic medical record elements; writing the basic information of the current patient into a plurality of corresponding basic medical record elements; receiving an instruction of adding a target medical record element; adding the target medical record element in the medical record template according to the instruction; when receiving input medical record information, writing the medical record information into a corresponding target medical record element; and generating an electronic medical record based on the basic medical record elements and the target medical record elements. This embodiment can make medical personnel confirm the information that the case history was expected to be recorded according to the actual demand through add the case history element in the case history template, has made things convenient for medical personnel to write the case history, has improved the efficiency of writing of case history.
Description
Technical Field
The invention belongs to the technical field of medical record management, and particularly relates to a method for generating an electronic medical record, a device for generating the electronic medical record, a terminal device and a computer-readable storage medium.
Background
In the medical industry, writing of medical records is a task that medical personnel are often faced with. The medical record, also called history and case, is the text record of the patient's disease process and treatment by the medical staff. The medical history is the basis for the diagnosis and treatment of diseases by doctors and is valuable data for medical science research. According to different use environments, medical records are divided into a plurality of types, wherein writing in the form of nursing medical records is relatively more complicated.
The nursing case history is a general name of data such as characters, symbols, icons and the like formed by nursing staff in the medical and nursing activities, is used for recording the state of illness, the treatment condition and the adopted nursing measures of a patient by nurses, and is a concrete embodiment and evidence for solving the actual problems and the process of the patients by nursing programs of the nurses. Because the nursing medical records are generally inpatient medical records and need to be recorded regularly according to the inpatient hospitalization time, the recording contents are more and the recording time is long compared with other types of medical records, the workload of nursing staff is increased seriously, and the writing efficiency of the medical record is influenced.
Disclosure of Invention
In view of this, embodiments of the present invention provide a method and an apparatus for generating an electronic medical record, so as to solve the problem that writing of a medical record in the prior art is very complicated.
The first aspect of the embodiment of the present invention provides a method for generating an electronic medical record, including:
determining basic information of a current patient and a medical record template to be used, wherein the medical record template comprises a plurality of basic medical record elements;
writing the basic information of the current patient into a plurality of corresponding basic medical record elements;
receiving an instruction of adding a target medical record element;
adding the target medical record element in the medical record template according to the instruction;
when receiving input medical record information, writing the medical record information into a corresponding target medical record element;
and generating an electronic medical record based on the basic medical record elements and the target medical record elements.
A second aspect of the embodiments of the present invention provides an apparatus for generating an electronic medical record, including:
the system comprises a determining module, a judging module and a judging module, wherein the determining module is used for determining basic information of a current patient and a medical record template to be used, and the medical record template comprises a plurality of basic medical record elements;
the first writing module is used for writing the basic information of the current patient into a plurality of corresponding basic medical record elements;
the receiving module is used for receiving an instruction of adding a target medical record element;
the adding module is used for adding the target medical record element in the medical record template aiming at the instruction;
the second writing module is used for writing the medical record information into the corresponding target medical record element when receiving the input medical record information;
and the generating module is used for generating the electronic medical record based on the basic medical record elements and the target medical record elements.
A third aspect of the embodiments of the present invention provides a terminal device, including a memory, a processor, and a computer program stored in the memory and executable on the processor, where the processor implements the steps of the method for generating an electronic medical record when executing the computer program.
A fourth aspect of the embodiments of the present invention provides a computer-readable storage medium, where a computer program is stored, and when the computer program is executed by a processor, the steps of the method for generating an electronic medical record are implemented.
Compared with the background art, the embodiment of the invention has the following advantages:
according to the embodiment of the invention, the basic information of the current patient and the medical record template to be used are determined, so that the basic information of the current patient can be written into the corresponding multiple basic medical record elements, and after an instruction for adding a new target medical record element is received, the target medical record element can be added into the medical record template aiming at the instruction, so that when the input medical record information is received, the medical record information can be written into the corresponding target medical record element, and the electronic medical record is generated based on the basic medical record element and the target medical record element. This embodiment can make medical personnel confirm the information that the case history was expected to be recorded according to the actual demand through add the case history element in the case history template, has made things convenient for medical personnel to write the case history, has improved the efficiency of writing of case history. In addition, the electronic medical record that this embodiment provided has still provided multiple editing function, and medical personnel can adopt corresponding editing function to edit the case history according to actual conditions, guarantees the format specification of case history.
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In order to more clearly illustrate the technical solutions in the embodiments of the present invention, the drawings used in the embodiments or the description of the prior art will be briefly described below. It is obvious that the drawings in the following description are only some embodiments of the invention, and that for a person skilled in the art, other drawings can be derived from them without inventive effort.
FIG. 1 is a flow chart illustrating steps of a method for generating an electronic medical record according to an embodiment of the invention;
FIG. 2 is a schematic diagram of an application environment of an electronic medical record according to an embodiment of the invention;
FIG. 3 is a schematic diagram of an electronic medical record editing tool according to one embodiment of the invention;
FIG. 4 is a diagram illustrating the editing functionality of medical records according to one embodiment of the present invention;
FIG. 5 is a schematic diagram of a process for generating an electronic medical record according to an embodiment of the invention;
FIG. 6 is a diagram of an apparatus for generating an electronic medical record according to an embodiment of the invention;
fig. 7 is a schematic diagram of a terminal device according to an embodiment of the present invention.
Detailed Description
In the following description, for purposes of explanation and not limitation, specific details are set forth, such as particular system structures, techniques, etc. in order to provide a thorough understanding of the embodiments of the invention. It will be apparent, however, to one skilled in the art that the present invention may be practiced in other embodiments that depart from these specific details. In other instances, detailed descriptions of well-known systems, devices, circuits, and methods are omitted so as not to obscure the description of the present invention with unnecessary detail.
The technical solution of the present invention will be described below by way of specific examples.
Referring to fig. 1, a schematic flow chart illustrating steps of a method for generating an electronic medical record according to an embodiment of the present invention is shown, which may specifically include the following steps:
s101, determining basic information of a current patient and a medical record template to be used, wherein the medical record template comprises a plurality of basic medical record elements;
it should be noted that the method can be applied to various terminal devices. Such as a tablet computer, a portable handheld device, or other similar electronic devices, but the present embodiment is not limited thereto.
Generally, in the process of nursing a patient, a medical worker needs to record treatment and rehabilitation conditions of the patient and fill in a nursing medical record as reference data for subsequent treatment.
In the embodiment of the invention, in order to improve the recording efficiency of the nursing medical records, the writing of the nursing medical records can be realized through a specific information system in a paperless mode.
In a specific implementation, when a medical staff needs to record a nursing duration, basic information of a current patient and a medical record template to be used can be determined firstly.
The current patient's basic information may be entered into the hospital information system at the time of patient admission, so that it can be directly obtained from the information system during the period of writing a nursing care.
The medical record template to be used can be selected by medical staff according to the actual treatment condition of the patient. For example, the corresponding medical record template can be selected according to the department where the patient is located.
In the embodiment of the invention, developers of the hospital information system can create different types of medical record templates in advance according to actual conditions of various departments or various disease categories. When a medical staff member needs to write a nursing care duration, a template of a certain type can be directly selected in the system.
The medical record template can include a plurality of basic medical record elements, such as patient name, age, medical history, contact information, contact persons, and the like.
S102, writing the basic information of the current patient into a plurality of corresponding basic medical record elements;
in the embodiment of the invention, after the basic information of the current patient is acquired from the hospital information system, the basic information can be written into each basic medical record element in the selected medical record template.
In a specific implementation, the medical record element items corresponding to each piece of basic information of the current patient can be identified first, and it is determined which medical record element in the selected medical record template corresponds to each piece of basic information. Then, the basic information recorded under the medical record element items can be written into the corresponding basic medical record elements respectively.
S103, receiving an instruction of a newly added target medical record element;
generally, each medical record element included in the medical record template is a common item. Aiming at actual needs, medical staff can add medical record elements in the medical record template.
In a specific implementation, the medical staff can send an instruction for adding a new target medical record element by clicking the name or example of a certain medical record element.
S104, aiming at the instruction, adding the target medical record element into the medical record template;
in the embodiment of the invention, before adding the target medical record element to the currently used medical record template, the length and width information of the target medical record element can be determined, and then the table with the length and width information is added to the medical record template to serve as the target medical record element, so that the specification of the finally generated electronic medical record format is ensured.
S105, when the input medical record information is received, writing the medical record information into a corresponding target medical record element;
note that the medical record information may be input by writing or editing in the terminal device by the medical staff. For example, the medical staff may input medical record information, i.e., treatment or rehabilitation information of the patient that should be recorded in the medical record, through an external input such as an electronic pen or a keyboard.
In the embodiment of the invention, medical staff can correspondingly input according to the medical record elements selected in the medical record template, and the input information can be recorded under the corresponding medical record elements in the template in real time.
And S106, generating an electronic medical record based on the basic medical record elements and the target medical record elements.
After the medical staff inputs the corresponding records according to the target medical record elements, the electronic medical record can be generated according to the complete records and stored in a database of the hospital information system, so that each subsystem of the hospital information system can call the electronic medical record.
Fig. 2 is a schematic diagram of an application environment of an electronic medical record according to an embodiment of the present invention. In fig. 2, the electronic medical record can be called by a plurality of subsystems of hospital information systems such as a resident doctor subsystem, a resident nurse subsystem, a medical record subsystem, an operation workstation and the like, so that medical staff can conveniently know treatment and rehabilitation conditions of a patient during hospitalization.
Fig. 3 is a schematic diagram of an electronic medical record editing tool according to an embodiment of the invention. Various editing instructions, such as cutting and pasting, font setting, paper setting, margin setting, header and footer setting, medical record writing, medical record format setting, paragraph setting, style setting, printing, etc., which can be provided by the electronic medical record generated according to the method described in the embodiment of the invention are shown in fig. 3.
Through the editing tool shown in fig. 3, the medical record editing functions shown in fig. 4 can be implemented, such as calling a template, adding a new medical record page, automatically separating rows, printing medical records, fixing tables, fixing headers, and the like.
As an example of the invention, medical staff can add a new medical record page when writing a disease.
In the embodiment of the present invention, when an instruction of adding a new medical record page is received, a plurality of basic medical record elements and the basic information of the current patient recorded in the plurality of basic medical record elements may be first obtained, and then after a new medical record page is generated, the plurality of basic medical record elements and the basic information of the current patient may be written in the new medical record page.
In concrete realization, medical personnel can select to increase new case history page in the toolbar, and the system can automatically increase an empty page with patient basic information according to the case history template that current case history called, and the basic information of current patient can all be attached to in each case history page, has standardized the writing of nursing case history, has improved and has written efficiency.
As another example of the invention, for the medical record elements with the fixed table height, the table head items can be added according to the illness state of the patient, and the medical record is subjected to paging processing.
In the embodiment of the present invention, when a paging instruction for a target medical record element is received, a new table may be generated in a new medical record page, and then a medical record header of the target medical record element is written in the new table.
In the embodiment of the invention, aiming at the problem that the page display of the electronic medical records is not uniform after medical staff add or delete certain medical record records when writing nursing diseases, the embodiment also provides the function of one-key typesetting on the electronic medical records so as to ensure the beauty and uniform format of the nursing record pages in the electronic medical records.
In a specific implementation, when an instruction to delete or add a specific medical record element is received, a medical record header in the electronic medical record may be fixed first, and then after the specific medical record element is deleted or added, the current medical record element is typeset again based on the fixed medical record header.
Generally, the key of one-key typesetting is to fix a header in a medical record template. Thus, it is possible to identify which of the pages is the header at the time of typesetting, and then to ensure that each page starts with the header and that the header is consistent with the current patient care record.
Meanwhile, when the one-key typesetting is performed, the first page can be used as a template. If the nursing records of the current patient need to be changed, for example, a signature of an executive nurse is added to each nursing record, only a signature column needs to be added to the first page, so that after the one-key typesetting function is executed, the function can automatically generate a signature column of the executive nurse in each page.
As still another example of the present invention, retrieval of electronic medical records may also be implemented by a hospital information system.
In specific implementation, after a retrieval request aiming at the electronic medical record is received, the electronic medical record matched with the patient ID can be searched from the medical record database according to the patient ID carried in the retrieval request, so that the quick retrieval of the health record of the patient is realized, and more historical reference data can be provided for the treatment decision of medical staff.
In the embodiment of the invention, the basic information of the current patient and the medical record template to be used are determined, so that the basic information of the current patient can be written into the corresponding multiple basic medical record elements, and after an instruction for adding a new target medical record element is received, the target medical record element can be added into the medical record template aiming at the instruction, so that when the input medical record information is received, the medical record information can be written into the corresponding target medical record element, and the electronic medical record is generated based on the basic medical record element and the target medical record element. This embodiment can make medical personnel confirm the information that the case history was expected to be recorded according to the actual demand through add the case history element in the case history template, has made things convenient for medical personnel to write the case history, has improved the efficiency of writing of case history. In addition, the electronic medical record that this embodiment provided has still provided multiple editing function, and medical personnel can adopt corresponding editing function to edit the case history according to actual conditions, guarantees the format specification of case history.
Fig. 5 is a schematic diagram illustrating a generation flow of an electronic medical record according to an embodiment of the present invention. When the electronic medical record is used, a medical record template can be manufactured through a medical record system, medical staff can quote the medical record template through an inpatient system and the like, and each medical record element item in the medical record template is filled according to actual needs. The finished electronic medical records can be stored in a medical record database or printed out and then filed.
It should be noted that, the sequence numbers of the steps in the foregoing embodiments do not mean the execution sequence, and the execution sequence of each process should be determined by the function and the internal logic of the process, and should not constitute any limitation on the implementation process of the embodiments of the present invention.
Referring to fig. 6, a schematic diagram of an apparatus for generating an electronic medical record according to an embodiment of the present invention is shown, which may specifically include the following modules:
a determining module 601, configured to determine basic information of a current patient and a medical record template to be used, where the medical record template includes a plurality of basic medical record elements;
a first writing module 602, configured to write the basic information of the current patient into a plurality of corresponding basic medical record elements;
a receiving module 603, configured to receive an instruction for adding a new target medical record element;
an adding module 604, configured to add the target medical record element to the medical record template according to the instruction;
a second writing module 605, configured to write the medical record information into a corresponding target medical record element when receiving input medical record information;
a generating module 606, configured to generate an electronic medical record based on the basic medical record element and the target medical record element.
In this embodiment of the present invention, the first writing module 602 may specifically include the following sub-modules:
the medical record element item identification submodule is used for identifying medical record element items corresponding to all basic information of the current patient;
and the basic information writing sub-module is used for respectively writing the basic information recorded under the medical record element items into corresponding basic medical record elements.
In this embodiment of the present invention, the adding module 604 may specifically include the following sub-modules:
the length and width information determining submodule is used for determining the length and width information of the target medical record element;
and the target medical record element adding submodule is used for adding a table with the length and width information in the medical record template as the target medical record element.
In the embodiment of the present invention, the apparatus may further include the following modules:
a basic medical record element acquiring module, configured to acquire the multiple basic medical record elements and the basic information of the current patient recorded in the multiple basic medical record elements when receiving an instruction of a new medical record page;
and the new medical record page generating module is used for generating a new medical record page and writing the plurality of basic medical record elements and the basic information of the current patient into the new medical record page.
In the embodiment of the present invention, the apparatus may further include the following modules:
and the paging module is used for generating a new table in the new medical record page when a paging instruction aiming at the target medical record element is received, wherein the target medical record element has a corresponding medical record table header, and the medical record table header of the target medical record element is written in the new table.
In the embodiment of the present invention, the apparatus may further include the following modules:
the medical record header fixing module is used for fixing the medical record header in the electronic medical record when receiving an instruction of deleting or adding a specific medical record element;
and the typesetting module is used for typesetting the current medical record elements again based on the fixed medical record header after the specific medical record elements are deleted or added.
In the embodiment of the present invention, the apparatus may further include the following modules:
the system comprises a retrieval request receiving module, a retrieval request processing module and a retrieval request processing module, wherein the retrieval request receiving module is used for receiving a retrieval request aiming at an electronic medical record, and the retrieval request carries a patient ID;
and the electronic medical record searching module is used for searching the electronic medical record matched with the patient ID from a medical record database according to the patient ID.
For the apparatus embodiment, since it is substantially similar to the method embodiment, it is described relatively simply, and reference may be made to the description of the method embodiment section for relevant points.
Referring to fig. 7, a schematic diagram of a terminal device according to an embodiment of the present invention is shown. As shown in fig. 7, the terminal device 700 of the present embodiment includes: a processor 710, a memory 720, and a computer program 721 stored in said memory 720 and operable on said processor 710. The processor 710, when executing the computer program 721, implements the steps in the various embodiments of the method for generating an electronic medical record, such as the steps S101 to S106 shown in fig. 1. Alternatively, the processor 710, when executing the computer program 721, implements the functions of each module/unit in each device embodiment described above, for example, the functions of the modules 601 to 606 shown in fig. 6.
Illustratively, the computer program 721 may be divided into one or more modules/units, which are stored in the memory 720 and executed by the processor 710 to implement the invention. The one or more modules/units may be a series of computer program instruction segments capable of performing specific functions, which may be used to describe the execution of the computer program 721 in the terminal device 700. For example, the computer program 721 may be divided into a determining module, a first writing module, a receiving module, an adding module, a second writing module, and a generating module, and the specific functions of each module are as follows:
the system comprises a determining module, a judging module and a judging module, wherein the determining module is used for determining basic information of a current patient and a medical record template to be used, and the medical record template comprises a plurality of basic medical record elements;
the first writing module is used for writing the basic information of the current patient into a plurality of corresponding basic medical record elements;
the receiving module is used for receiving an instruction of adding a target medical record element;
the adding module is used for adding the target medical record element in the medical record template aiming at the instruction;
the second writing module is used for writing the medical record information into the corresponding target medical record element when receiving the input medical record information;
and the generating module is used for generating the electronic medical record based on the basic medical record elements and the target medical record elements.
The terminal device 700 may be a desktop computer, a notebook, a palm computer, a cloud server, or other computing devices. The terminal device 700 may include, but is not limited to, a processor 710, a memory 720. Those skilled in the art will appreciate that fig. 7 is only one example of a terminal device 700 and does not constitute a limitation of the terminal device 700 and may include more or less components than those shown, or combine certain components, or different components, for example, the terminal device 700 may also include input output devices, network access devices, buses, etc.
The Processor 710 may be a Central Processing Unit (CPU), other general purpose Processor, a Digital Signal Processor (DSP), an Application Specific Integrated Circuit (ASIC), an off-the-shelf Programmable Gate Array (FPGA) or other Programmable logic device, discrete Gate or transistor logic device, discrete hardware component, etc. A general purpose processor may be a microprocessor or the processor may be any conventional processor or the like.
The memory 720 may be an internal storage unit of the terminal device 700, such as a hard disk or a memory of the terminal device 700. The memory 720 may also be an external storage device of the terminal device 700, such as a plug-in hard disk, a Smart Media Card (SMC), a Secure Digital (SD) Card, a Flash memory Card (Flash Card), and so on, provided on the terminal device 700. Further, the memory 720 may also include both an internal storage unit and an external storage device of the terminal device 700. The memory 720 is used for storing the computer program 721 and other programs and data required by the terminal device 700. The memory 720 may also be used to temporarily store data that has been output or is to be output.
It will be apparent to those skilled in the art that the foregoing division of the functional units and modules is merely illustrative for the convenience and simplicity of description. In practical applications, the above function allocation may be performed by different functional units or modules as needed, that is, the internal structure of the apparatus/terminal device is divided into different functional units or modules, so as to perform all or part of the above described functions. Each functional unit and module in the embodiments may be integrated in one processing unit, or each unit may exist alone physically, or two or more units are integrated in one unit, and the integrated unit may be implemented in a form of hardware, or in a form of software functional unit. In addition, specific names of the functional units and modules are only for convenience of distinguishing from each other, and are not used for limiting the protection scope of the present invention. The specific working processes of the units and modules in the system may refer to the corresponding processes in the foregoing method embodiments, and are not described herein again.
In the above embodiments, the descriptions of the respective embodiments have respective emphasis, and reference may be made to the related descriptions of other embodiments for parts that are not described or illustrated in a certain embodiment.
Those of ordinary skill in the art will appreciate that the various illustrative elements and algorithm steps described in connection with the embodiments disclosed herein may be implemented as electronic hardware or combinations of computer software and electronic hardware. Whether such functionality is implemented as hardware or software depends upon the particular application and design constraints imposed on the implementation. Skilled artisans may implement the described functionality in varying ways for each particular application, but such implementation decisions should not be interpreted as causing a departure from the scope of the present invention.
In the embodiments provided in the present invention, it should be understood that the disclosed apparatus/terminal device and method may be implemented in other ways. For example, the above-described embodiments of the apparatus/terminal device are merely illustrative, and for example, the division of the modules or units is only one logical division, and there may be other divisions when actually implemented, for example, a plurality of units or components may be combined or integrated into another system, or some features may be omitted, or not executed. On the other hand, the shown or discussed mutual coupling or direct coupling or communication connection may be an indirect coupling or communication connection through some interfaces, devices or units, and may be in an electrical, mechanical or other form.
The units described as separate parts may or may not be physically separate, and parts displayed as units may or may not be physical units, may be located in one place, or may be distributed on a plurality of network units. Some or all of the units can be selected according to actual needs to achieve the purpose of the solution of the embodiment.
In addition, functional units in the embodiments of the present invention may be integrated into one processing unit, or each unit may exist alone physically, or two or more units are integrated into one unit. The integrated unit can be realized in a form of hardware, and can also be realized in a form of a software functional unit.
The integrated modules/units, if implemented in the form of software functional units and sold or used as separate products, may be stored in a computer readable storage medium. Based on such understanding, all or part of the flow in the method according to the above embodiments may be implemented by a computer program, which may be stored in a computer readable storage medium and used by a processor to implement the steps of the above embodiments of the method. Wherein the computer program comprises computer program code, which may be in the form of source code, object code, an executable file or some intermediate form, etc. The computer-readable storage medium may include: any entity or device capable of carrying the computer program code, recording medium, usb disk, removable hard disk, magnetic disk, optical disk, computer Memory, Read-Only Memory (ROM), Random Access Memory (RAM), electrical carrier wave signals, telecommunications signals, software distribution medium, and the like. It should be noted that the computer readable storage medium may contain content that is subject to appropriate increase or decrease as required by legislation and patent practice in jurisdictions, for example, in some jurisdictions, computer readable storage media that does not include electrical carrier signals and telecommunications signals in accordance with legislation and patent practice.
The above-mentioned embodiments are only used for illustrating the technical solutions of the present invention, and not for limiting the same. Although the present invention has been described in detail with reference to the foregoing embodiments, it will be understood by those of ordinary skill in the art that: the technical solutions described in the foregoing embodiments may still be modified, or some technical features may be equivalently replaced; such modifications and substitutions do not substantially depart from the spirit and scope of the embodiments of the present invention, and are intended to be included within the scope of the present invention.
Claims (10)
1. A method for generating an electronic medical record is characterized by comprising the following steps:
determining basic information of a current patient and a medical record template to be used, wherein the medical record template comprises a plurality of basic medical record elements;
writing the basic information of the current patient into a plurality of corresponding basic medical record elements;
receiving an instruction of adding a target medical record element;
adding the target medical record element in the medical record template according to the instruction;
when receiving input medical record information, writing the medical record information into a corresponding target medical record element;
and generating an electronic medical record based on the basic medical record elements and the target medical record elements.
2. The method of claim 1, wherein writing the current patient's basic information into a corresponding plurality of basic medical record elements comprises:
identifying medical record element items corresponding to each piece of basic information of the current patient;
and respectively writing the basic information recorded under the medical record element items into corresponding basic medical record elements.
3. The method according to claim 2, wherein the step of adding the target medical record element in the medical record template for the instruction comprises:
determining length and width information of the target medical record element;
and adding a table with the length and width information in the medical record template as the target medical record element.
4. The method of claim 1, further comprising:
when an instruction of adding a new medical record page is received, acquiring the plurality of basic medical record elements and the basic information of the current patient recorded in the plurality of basic medical record elements;
and generating a new medical record page, and writing the plurality of basic medical record elements and the basic information of the current patient into the new medical record page.
5. The method of claim 4, further comprising:
when a paging instruction for the target medical record element is received, generating a new table in the new medical record page, wherein the target medical record element has a corresponding medical record header;
and writing the medical record header of the target medical record element into the new table.
6. The method of claim 5, further comprising:
when an instruction of deleting or adding a specific medical record element is received, fixing a medical record header in the electronic medical record;
and after the specific medical record elements are deleted or added, the current medical record elements are typeset again based on the fixed medical record headers.
7. The method of claim 1, further comprising:
receiving a retrieval request aiming at the electronic medical record, wherein the retrieval request carries a patient ID;
and searching the electronic medical record matched with the patient ID from a medical record database according to the patient ID.
8. An apparatus for generating an electronic medical record, comprising:
the system comprises a determining module, a judging module and a judging module, wherein the determining module is used for determining basic information of a current patient and a medical record template to be used, and the medical record template comprises a plurality of basic medical record elements;
the first writing module is used for writing the basic information of the current patient into a plurality of corresponding basic medical record elements;
the receiving module is used for receiving an instruction of adding a target medical record element;
the adding module is used for adding the target medical record element in the medical record template aiming at the instruction;
the second writing module is used for writing the medical record information into the corresponding target medical record element when receiving the input medical record information;
and the generating module is used for generating the electronic medical record based on the basic medical record elements and the target medical record elements.
9. A terminal device comprising a memory, a processor and a computer program stored in the memory and operable on the processor, wherein the processor implements the steps of the method for generating an electronic medical record according to any one of claims 1 to 7 when executing the computer program.
10. A computer-readable storage medium, which stores a computer program, wherein the computer program, when executed by a processor, implements the steps of the method for generating an electronic medical record according to any one of claims 1 to 7.
Priority Applications (1)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CN201811493965.3A CN111292817A (en) | 2018-12-07 | 2018-12-07 | Electronic medical record generation method and device |
Applications Claiming Priority (1)
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| CN111613286A (en) * | 2020-06-30 | 2020-09-01 | 成都中医药大学附属医院 | Outpatient traditional Chinese medicine electronic medical record system |
| CN111985197A (en) * | 2020-07-17 | 2020-11-24 | 北京欧应信息技术有限公司 | Template generation method based on medical information |
| CN112349367A (en) * | 2020-11-11 | 2021-02-09 | 北京嘉和海森健康科技有限公司 | Method and device for generating simulation medical record, electronic equipment and storage medium |
| CN113658650A (en) * | 2021-07-23 | 2021-11-16 | 深圳九明珠信息科技有限公司 | Electronic medical record filling task reminding method and computer equipment |
| CN113793677A (en) * | 2021-08-24 | 2021-12-14 | 挂号网（杭州）科技有限公司 | Electronic medical record management method and device, storage medium and electronic equipment |
| CN114360671A (en) * | 2020-09-28 | 2022-04-15 | 北京金山云网络技术有限公司 | Electronic medical record generation method and device, storage medium and electronic device |
| CN114675795A (en) * | 2022-04-02 | 2022-06-28 | 智业软件股份有限公司 | Method, device and storage medium for overprinting medical record |
| CN115906778A (en) * | 2023-01-05 | 2023-04-04 | 湖南创星科技股份有限公司 | Electronic medical record auxiliary writing method and device based on artificial intelligence |
| CN116453640A (en) * | 2023-06-15 | 2023-07-18 | 北京四海汇智科技有限公司 | Method and device for constructing clinical special disease library based on multi-label screening and electronic equipment |
| CN116525051A (en) * | 2023-06-29 | 2023-08-01 | 北京天健源达科技股份有限公司 | Electronic medical record processing method and device |
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| CN111613286A (en) * | 2020-06-30 | 2020-09-01 | 成都中医药大学附属医院 | Outpatient traditional Chinese medicine electronic medical record system |
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| CN113658650A (en) * | 2021-07-23 | 2021-11-16 | 深圳九明珠信息科技有限公司 | Electronic medical record filling task reminding method and computer equipment |
| CN113793677A (en) * | 2021-08-24 | 2021-12-14 | 挂号网（杭州）科技有限公司 | Electronic medical record management method and device, storage medium and electronic equipment |
| CN114675795A (en) * | 2022-04-02 | 2022-06-28 | 智业软件股份有限公司 | Method, device and storage medium for overprinting medical record |
| CN115906778A (en) * | 2023-01-05 | 2023-04-04 | 湖南创星科技股份有限公司 | Electronic medical record auxiliary writing method and device based on artificial intelligence |
| CN116453640A (en) * | 2023-06-15 | 2023-07-18 | 北京四海汇智科技有限公司 | Method and device for constructing clinical special disease library based on multi-label screening and electronic equipment |
| CN116453640B (en) * | 2023-06-15 | 2023-09-22 | 北京四海汇智科技有限公司 | Method and device for constructing clinical special disease library based on multi-label screening and electronic equipment |
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