CN111554370A - Electronic medical record auditing method and device - Google Patents
Electronic medical record auditing method and device Download PDFInfo
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- CN111554370A CN111554370A CN202010407077.6A CN202010407077A CN111554370A CN 111554370 A CN111554370 A CN 111554370A CN 202010407077 A CN202010407077 A CN 202010407077A CN 111554370 A CN111554370 A CN 111554370A
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Abstract
The invention discloses an electronic medical record auditing method and device, which are characterized in that when an auditing instruction of a medical record problem item is detected, a focus coordinate of the medical record problem item is obtained, an auditing opinion frame is displayed at the position of the focus coordinate, after auditing opinion content aiming at the medical record problem item is obtained, the auditing opinion content is added into the auditing opinion frame, and a problem item serial number is displayed at the position of the medical record problem item. According to the method, the review suggestion frame is displayed at the focal coordinate position of the medical record problem item, the review suggestion content is added into the review suggestion frame, and the medical record problem item is expressed by the problem item serial number, so that medical record writers can clearly see the distribution and the quantity of all medical record problem items, the medical record problem items can be quickly found, and the modification efficiency is improved.
Description
Technical Field
The invention relates to the technical field of medical treatment, in particular to an electronic medical record auditing method and device.
Background
The medical record is used as a record of the whole diagnosis and treatment process, and is not only a writing picture of sweat and heart blood of a doctor, but also a requirement for standard practice. The state has a clear standard of 'medical record writing standard' for writing medical records. Clinicians have the responsibility and obligation to write medical records on time, on project, and on a normative basis. In order to ensure the normative writing of medical records, the medical records written by doctors are generally required to be checked from five aspects of timeliness, integrity, logicality, rationality and normative, whether the medical records are falsified or not, whether the medical records are indiscriminately used and unreasonable used, whether the medical records are abundantly checked and repeatedly checked or whether the medical records are unreasonable charged and repeatedly charged and the like are checked, so that the working specification and the medical behavior specification are promoted, and the legal rights and interests of patients are guaranteed.
Whether the medical record is a paper medical record or an electronic medical record (the electronic medical record is a digital medical record stored, managed, transmitted and reproduced by electronic equipment and is used for replacing a handwritten paper medical record, the content of the electronic medical record comprises all information of the paper medical record), in the traditional medical record auditing process, when the medical record has unqualified items, a medical record auditor often edits a section of characters to describe the medical record auditing opinions, then the medical record added with the medical record auditing opinions is returned to a medical record writer, and the medical record writer searches for corresponding items in the medical record according to the medical record auditing opinions to modify the corresponding items.
In the prior art, a medical record auditor usually edits a section of text to describe a medical record audit suggestion at a certain fixed position of a medical record, such as the bottom of the medical record. Because the medical record examination opinions cannot display all problem distribution and problem quantity, when a medical record writer modifies a patient, the position of a medical record problem item needs to be checked repeatedly according to the medical record examination opinions. When the medical record content is more, the medical record writer needs to spend longer time searching the medical record problem items, thereby influencing the modification efficiency.
Disclosure of Invention
In view of the above, the invention discloses an electronic medical record auditing method and device, so as to display an auditing suggestion frame at the focus coordinate position of a medical record problem item, add auditing suggestion content in the auditing suggestion frame, and express the medical record problem item by a problem item serial number, so that a medical record writer can clearly see the distribution and the quantity of all medical record problem items, thereby quickly finding the medical record problem item and improving the modification efficiency.
An electronic medical record auditing method comprises the following steps:
when an auditing instruction of a medical record question item is detected, acquiring a focus coordinate of the medical record question item;
displaying an audit opinion frame at the position of the focus coordinate;
acquiring the auditing opinion content aiming at the medical record problem item;
adding the audit opinion content into the audit opinion frame, and storing the audit opinion frame added with the audit opinion content;
and displaying the sequence number of the question item at the position of the medical record question item.
Optionally, the audit suggestion frame is divided into an upper part, a middle part and a lower part, the upper part is a common suggestion description button which is arranged and distributed, the middle part is a suggestion input text box, and the lower part is a determination button and a cancel button.
Optionally, the review opinion content is generated after a medical record reviewer clicks a common opinion description button corresponding to the review opinion content, or is text content directly input by the medical record reviewer in the review opinion frame.
Optionally, the obtaining of the review opinion content for the medical record question item specifically includes:
when a selection instruction of the frequently-used opinion description button is detected, determining the selected frequently-used opinion description button as a target frequently-used opinion description button;
and searching the corresponding audit opinion content corresponding to the target common opinion description button from the corresponding relationship between the pre-stored common opinion description button and the audit opinion content.
Optionally, after the step of displaying the sequence number of the question item at the position of the medical record question item, the method further includes:
and adding related audit information of the medical record problem items into a preset problem item list, and storing the focus coordinates of the medical record problem items, wherein the related audit information added to the problem item list comprises the problem item serial numbers, and the problem item serial numbers are linked with the focus coordinates.
Optionally, the method further includes:
judging whether an unverified medical record problem item exists or not;
and if not, sending the checked electronic medical record to a client of a medical record writer.
Optionally, the method further includes:
when a modification instruction of the medical record problem items in the problem item list is detected, acquiring a target problem item sequence number and a target focus coordinate of the medical record problem item to be modified;
positioning the current electronic medical record interface to the position of the medical record problem item to be modified according to the sequence number of the target problem item and the target focus coordinate;
acquiring the modification content of the medical record problem item to be modified;
and adding the relevant modification information of the medical record question item to be modified into the question item list.
An electronic medical record auditing apparatus, comprising:
the first acquisition unit is used for acquiring the focus coordinate of the medical record question item when an auditing instruction of the medical record question item is detected;
the first display unit is used for displaying an audit opinion frame at the position of the focus coordinate;
the second acquisition unit is used for acquiring the auditing opinion content aiming at the medical record question item;
the first adding unit is used for adding the audit opinion content into the audit opinion frame and storing the audit opinion frame added with the audit opinion content;
and the second display unit is used for displaying the sequence number of the question item at the position of the medical record question item.
Optionally, the audit suggestion frame is divided into an upper part, a middle part and a lower part, the upper part is a common suggestion description button which is arranged and distributed, the middle part is a suggestion input text box, and the lower part is a determination button and a cancel button.
Optionally, the second obtaining unit is specifically configured to:
when a selection instruction of the frequently-used opinion description button is detected, determining the selected frequently-used opinion description button as a target frequently-used opinion description button;
and searching the corresponding audit opinion content corresponding to the target common opinion description button from the corresponding relationship between the pre-stored common opinion description button and the audit opinion content.
Optionally, the method further includes:
and the second adding unit is used for adding related auditing information of the medical record question items to a preset question item list after the second display unit displays the question item serial numbers at the positions of the medical record question items, and storing the focus coordinates of the medical record question items, wherein the related auditing information added to the question item list comprises the question item serial numbers, and the question item serial numbers are linked with the focus coordinates.
Optionally, the method further includes:
the judging unit is used for judging whether an unverified medical record problem item exists or not;
and the sending unit is used for sending the checked electronic medical record to the client of the medical record writer under the condition that the judging unit judges that the electronic medical record is not checked.
Optionally, the method further includes:
a third obtaining unit, configured to obtain, when a modification instruction for a medical record question item in the question item list is detected, a target question item sequence number and a target focus coordinate of the medical record question item to be modified;
the positioning unit is used for positioning the current electronic medical record interface to the position of the medical record problem item to be modified according to the sequence number of the target problem item and the target focus coordinate;
a fourth obtaining unit, configured to obtain modification content for the medical record question item to be modified;
and the third adding unit is used for adding the relevant modification information of the medical record question item to be modified into the question item list.
According to the technical scheme, when an examination instruction of a problem item of the medical record is detected, the focus coordinate of the problem item of the medical record is obtained, an examination opinion frame is displayed at the position of the focus coordinate, after examination opinion content aiming at the problem item of the medical record is obtained, the examination opinion content is added into the examination opinion frame, and the sequence number of the problem item is displayed at the position of the problem item of the medical record. According to the method, the review suggestion frame is displayed at the focal coordinate position of the medical record problem item, the review suggestion content is added into the review suggestion frame, and the medical record problem item is expressed by the problem item serial number, so that medical record writers can clearly see the distribution and the quantity of all medical record problem items, the medical record problem items can be quickly found, and the modification efficiency is improved.
Drawings
In order to more clearly illustrate the embodiments of the present invention or the technical solutions in the prior art, the drawings used in the description of the embodiments or the prior art will be briefly described below, it is obvious that the drawings in the following description are only embodiments of the present invention, and for those skilled in the art, other drawings can be obtained according to the disclosed drawings without creative efforts.
FIG. 1 is a flowchart of an electronic medical record auditing method according to an embodiment of the present invention;
FIG. 2 is a flowchart of another method for auditing an electronic medical record according to an embodiment of the present invention;
FIG. 3 is a flowchart of a method for modifying an electronic medical record according to an embodiment of the present invention;
fig. 4 is a schematic structural diagram of an electronic medical record auditing apparatus according to an embodiment of the present invention;
fig. 5 is a schematic structural diagram of another electronic medical record auditing apparatus according to the embodiment of the present invention.
Detailed Description
The technical solutions in the embodiments of the present invention will be clearly and completely described below with reference to the drawings in the embodiments of the present invention, and it is obvious that the described embodiments are only a part of the embodiments of the present invention, and not all of the embodiments. All other embodiments, which can be derived by a person skilled in the art from the embodiments given herein without making any creative effort, shall fall within the protection scope of the present invention.
The embodiment of the invention discloses an electronic medical record auditing method and device, which are characterized in that when an auditing instruction of a medical record problem item is detected, a focus coordinate of the medical record problem item is obtained, an auditing suggestion frame is displayed at the position of the focus coordinate, after auditing suggestion contents aiming at the medical record problem item are obtained, the auditing suggestion contents are added into the auditing suggestion frame, and a problem item serial number is displayed at the position of the medical record problem item. According to the method, the review suggestion frame is displayed at the focal coordinate position of the medical record problem item, the review suggestion content is added into the review suggestion frame, and the medical record problem item is expressed by the problem item serial number, so that medical record writers can clearly see the distribution and the quantity of all medical record problem items, the medical record problem items can be quickly found, and the modification efficiency is improved.
Referring to fig. 1, a flowchart of an electronic medical record auditing method disclosed in an embodiment of the present invention includes the steps of:
step S101, when an auditing instruction of a medical record question item is detected, acquiring a focus coordinate of the medical record question item;
when the medical record auditor audits the medical record, the medical record auditor can generate the audit instruction by double clicking the medical record question item.
Medical record auditing refers to: the medical record auditor checks whether the medical record items are complete and the content is complete according to the medical record writing standard, so as to prevent missing pages and few items, whether the medical record is completed in time, whether the writing, diagnosis, treatment, management and operation of the medical record meet the standard, and whether the diagnosis, medication and charging of the medical record are reasonable.
The focal coordinates of the medical record question items refer to the positions of the medical record question items on the screen, namely the horizontal and vertical coordinates of the medical record question items on the screen.
Step S102, displaying an audit opinion frame at the position of the focus coordinate;
specifically, the audit opinion box can be divided into an upper part, a middle part and a lower part, wherein the upper part is a common opinion description button which is arranged and distributed, the middle part is an opinion input text box, and the lower part is a determination button and a cancel button.
Step S103, acquiring the review opinion content aiming at the medical record question item;
the review opinion content can be generated after a medical record reviewer clicks a common opinion description button corresponding to the review opinion content, or text content directly input by the medical record reviewer in the review opinion frame.
It should be noted that the contents of the audit opinions in the audit opinion box are editable texts.
Specifically, when the medical record auditor adds the audit opinion content aiming at the medical record problem items in the audit opinion frame, the medical record auditor can select the required common opinion description buttons from the arranged and distributed common opinion description buttons according to the actual requirement, generate the corresponding audit opinion content, and display the corresponding audit opinion content in the audit opinion frame. In practical application, the medical record auditor can edit the audit opinion content displayed in the audit opinion box. When the arranged and distributed common opinion description buttons do not have buttons corresponding to the required audit opinion contents, the medical record auditor can directly input the audit opinion contents in the audit opinion frame.
Therefore, step S103 may specifically include:
when a selection instruction of the frequently-used opinion description button is detected, determining the selected frequently-used opinion description button as a target frequently-used opinion description button;
and searching the corresponding audit opinion content corresponding to the target common opinion description button from the corresponding relationship between the pre-stored common opinion description button and the audit opinion content.
It can be understood that most of the problems of the medical records have a certain commonality, and in the conventional scheme, similar characters are usually required to be edited repeatedly when the examination opinion content is filled in, so that the examination efficiency of the medical records is low.
In order to solve the problem, the commonly used opinion description is presented in a form of a quick button, namely a commonly used opinion description button, so that when a medical record auditor needs to input commonly used audit opinion contents in an audit opinion frame, the needed audit opinion contents can be added into the audit opinion frame by directly clicking the corresponding commonly used opinion description button, and the audit opinion contents in the audit opinion frame can be edited, thereby greatly improving the audit efficiency.
Step S104, adding the audit opinion content into the audit opinion frame, and storing the audit opinion frame added with the audit opinion content;
specifically, after the audit opinion content is completely added to the audit opinion frame, the medical record auditor can save the audit opinion frame to which the audit opinion content has been added by clicking a determination button in the audit opinion frame.
And step S105, displaying the sequence number of the question item at the position of the medical record question item.
Wherein, the serial number of the question item refers to: the sequence number of each medical record question item in all medical record question items, for example, the sequence number of the question item is 01, which represents the 01 th medical record question item, the sequence number of the question item is 02, which represents the 02 th medical record question item, and so on.
It should be noted that, in practical applications, in order to facilitate searching for each medical record question item, the serial number of each question item may be labeled with a color, for example, the color of the serial number of the question item is red.
In summary, according to the electronic medical record auditing method disclosed by the invention, when an auditing instruction for a medical record problem item is detected, a focus coordinate of the medical record problem item is obtained, an auditing suggestion frame is displayed at the position of the focus coordinate, after auditing suggestion content aiming at the medical record problem item is obtained, the auditing suggestion content is added into the auditing suggestion frame, and a problem item serial number is displayed at the position of the medical record problem item. According to the method, the review suggestion frame is displayed at the focal coordinate position of the medical record problem item, the review suggestion content is added into the review suggestion frame, and the medical record problem item is expressed by the problem item serial number, so that medical record writers can clearly see the distribution and the quantity of all medical record problem items, the medical record problem items can be quickly found, and the modification efficiency is improved.
In the traditional scheme, all examination and verification opinion contents of medical records are a section of descriptive characters, so that a medical record writer is required to search corresponding medical record problem items from the medical records according to the description of the examination and verification opinion contents, modification efficiency is influenced, and errors are easy to occur in the process of modifying the medical record problem items.
Based on this, in order to further optimize the above embodiment, referring to fig. 2, a flowchart of an electronic medical record auditing method disclosed in another embodiment of the present invention may further include, after step S105, on the basis of the embodiment shown in fig. 1:
and S106, adding the related auditing information of the medical record question items to a preset question item list, and storing the focus coordinates of the medical record question items.
The related auditing information added to the problem item list comprises the problem item serial number, and the problem item serial number is linked with the focus coordinate of the corresponding medical record problem item.
The related auditing information of the medical record question item can comprise: the problem item serial number, the medical record auditor, the auditing time, the medical record problem item and the auditing opinion content, and the like.
In summary, according to the electronic medical record auditing method disclosed by the invention, when an auditing instruction for a medical record problem item is detected, a focus coordinate of the medical record problem item is obtained, an auditing suggestion frame is displayed at the position of the focus coordinate, after auditing suggestion content aiming at the medical record problem item is obtained, the auditing suggestion content is added into the auditing suggestion frame, and a problem item serial number is displayed at the position of the medical record problem item. Because the invention displays the review opinion frame at the focus coordinate position of the medical record question item, so as to add the review opinion content and express the medical record question item by the question item serial number, the medical record writer can clearly see the distribution and the quantity of all the medical record question items. Meanwhile, all medical record problem items are added to the problem item list, and the problem item serial numbers in the problem item list are linked with the focus coordinates of the corresponding medical record problem items, so that when a certain row in the problem item list is selected, the position of the corresponding medical record problem item can be directly positioned according to the focus coordinates corresponding to the medical record problem items in the row, the speed of searching the medical record problem items is increased, and the occurrence of modification errors caused by positioning errors of the medical record problem items is effectively avoided.
In addition, compared with the traditional scheme, all medical record auditing opinions are descriptive characters, so that the auditing opinions of all medical record problem items are not structurally stored, and the modification opinions of all medical record problem items are not structurally stored, so that auditing data are inconvenient to trace and analyze.
To further optimize the above embodiment, on the basis of step S106, the method may further include the steps of:
step S107, judging whether an unverified medical record problem item exists, if so, returning to the step S101, and if not, executing the step S108;
and step S108, sending the checked electronic medical record to a client of a medical record writer.
It can be understood that after the electronic medical record after being checked is sent to the client of the medical record writer, the medical record writer can modify and perfect the electronic medical record according to the checking opinion content of each medical record problem item in the electronic medical record, so that the modified electronic medical record meets the medical record writing standard.
Therefore, in order to further optimize the embodiment, the invention also discloses a process for modifying the electronic medical record by a medical record writer.
Referring to fig. 3, a flowchart of an electronic medical record modifying method disclosed in an embodiment of the present invention includes the steps of:
step S201, when a modification instruction of a medical record problem item in a problem item list is detected, acquiring a target problem item sequence number and a target focus coordinate of the medical record problem item to be modified;
in practical application, when a medical record writer needs to modify a certain medical record question item in the question item list, the medical record writer can generate a modification instruction by double-clicking the row of the medical record question item to be selected.
Step S202, positioning the current electronic medical record interface to the position of the medical record problem item to be modified according to the sequence number of the target problem item and the target focus coordinate;
in practical application, in order to facilitate a medical record writer to quickly find the position of a medical record item to be modified, the sequence number of a target problem item of the medical record item to be modified can be highlighted, and the sequence number of the target problem item can be moved to the center of a screen.
Step S203, acquiring the modification content of the medical record question item to be modified;
when the electronic medical record interface is customized to the position of the medical record question item to be modified, the medical record writer can modify the medical record question item to be modified.
And step S204, adding relevant modification information of the medical record question item to be modified into the question item list.
Wherein the relevant modification information includes: the modification content, the medical record modification time, the medical record modifier and the medical record modification state and the like.
Specifically, the relevant modification information can be added to the row of the medical record question item to be modified in the question item list.
In summary, according to the electronic medical record auditing method disclosed by the invention, after the audited electronic medical record is sent to the client of the medical record writer, the medical record writer can generate a modification instruction by selecting the row of the medical record problem item, obtain the sequence number and the target focus coordinate of the target problem item of the medical record problem item to be modified, position the current electronic medical record interface to the position of the medical record problem item to be modified according to the sequence number and the target focus coordinate of the target problem item, modify the medical record problem item to be modified, and add the relevant modification information of the medical record problem item to be modified to the problem item list. According to the invention, the examination information of the medical record examiner and the modification information of the medical record writer are both stored in the problem item list, so that the structured storage of the examination information and the modification information is realized, and the statistical analysis of the medical record is conveniently and rapidly carried out.
To further optimize the above embodiment, after step S204, the method may further include:
and judging whether an unmodified medical record problem item exists, if so, returning to the step S201, and if so, ending the modification flow.
Corresponding to the embodiment of the method, the invention also discloses an electronic medical record auditing device.
Referring to fig. 4, a schematic structural diagram of an electronic medical record auditing apparatus disclosed in an embodiment of the present invention includes:
a first obtaining unit 301, configured to obtain a focus coordinate of a medical record question item when an audit instruction for the medical record question item is detected;
when the medical record auditor audits the medical record, the medical record auditor can generate the audit instruction by double clicking the medical record question item.
The focal coordinates of the medical record question items refer to the positions of the medical record question items on the screen, namely the horizontal and vertical coordinates of the medical record question items on the screen.
A first display unit 302 for displaying an audit suggestion frame at the position of the focus coordinate;
specifically, the audit opinion box can be divided into an upper part, a middle part and a lower part, wherein the upper part is a common opinion description button which is arranged and distributed, the middle part is an opinion input text box, and the lower part is a determination button and a cancel button.
A second obtaining unit 303, configured to obtain review opinion content for the medical record question item;
the review opinion content can be generated after a medical record reviewer clicks a common opinion description button corresponding to the review opinion content, or text content directly input by the medical record reviewer in the review opinion frame.
It should be noted that the contents of the audit opinions in the audit opinion box are editable texts.
Specifically, when the medical record auditor adds the audit opinion content aiming at the medical record problem items in the audit opinion frame, the medical record auditor can select the required common opinion description buttons from the arranged and distributed common opinion description buttons according to the actual requirement, generate the corresponding audit opinion content, and display the corresponding audit opinion content in the audit opinion frame. In practical application, the medical record auditor can edit the audit opinion content displayed in the audit opinion box. When the arranged and distributed common opinion description buttons do not have buttons corresponding to the required audit opinion contents, the medical record auditor can directly input the audit opinion contents in the audit opinion frame.
Therefore, the second obtaining unit 303 is specifically configured to:
when a selection instruction of the frequently-used opinion description button is detected, determining the selected frequently-used opinion description button as a target frequently-used opinion description button;
and searching the corresponding audit opinion content corresponding to the target common opinion description button from the corresponding relationship between the pre-stored common opinion description button and the audit opinion content.
It can be understood that most of the problems of the medical records have a certain commonality, and in the conventional scheme, similar characters are usually required to be edited repeatedly when the examination opinion content is filled in, so that the examination efficiency of the medical records is low.
In order to solve the problem, the commonly used opinion description is presented in a form of a quick button, namely a commonly used opinion description button, so that when a medical record auditor needs to input commonly used audit opinion contents in an audit opinion frame, the needed audit opinion contents can be added into the audit opinion frame by directly clicking the corresponding commonly used opinion description button, and the audit opinion contents in the audit opinion frame can be edited, thereby greatly improving the audit efficiency.
A first adding unit 304, configured to add the review comment content into the review comment frame, and store the review comment frame to which the review comment content has been added;
specifically, after the audit opinion content is completely added to the audit opinion frame, the medical record auditor can save the audit opinion frame to which the audit opinion content has been added by clicking a determination button in the audit opinion frame.
And a second display unit 305, configured to display the question item sequence number at the location of the medical record question item.
Wherein, the serial number of the question item refers to: the sequence number of each medical record question item in all medical record question items, for example, the sequence number of the question item is 01, which represents the 01 th medical record question item, the sequence number of the question item is 02, which represents the 02 th medical record question item, and so on.
It should be noted that, in practical applications, in order to facilitate searching for each medical record question item, the serial number of each question item may be labeled with a color, for example, the color of the serial number of the question item is red.
In summary, the electronic medical record auditing device disclosed by the invention acquires the focus coordinate of the medical record problem item when an auditing instruction of the medical record problem item is detected, displays the auditing suggestion frame at the position of the focus coordinate, adds the auditing suggestion content into the auditing suggestion frame after acquiring the auditing suggestion content aiming at the medical record problem item, and displays the problem item sequence number at the position of the medical record problem item. According to the method, the review suggestion frame is displayed at the focal coordinate position of the medical record problem item, the review suggestion content is added into the review suggestion frame, and the medical record problem item is expressed by the problem item serial number, so that medical record writers can clearly see the distribution and the quantity of all medical record problem items, the medical record problem items can be quickly found, and the modification efficiency is improved.
In the traditional scheme, all examination and verification opinion contents of medical records are a section of descriptive characters, so that a medical record writer is required to search corresponding medical record problem items from the medical records according to the description of the examination and verification opinion contents, modification efficiency is influenced, and errors are easy to occur in the process of modifying the medical record problem items.
Based on this, in order to further optimize the above embodiment, referring to fig. 5, a schematic structural diagram of an electronic medical record auditing apparatus disclosed in another embodiment of the present invention may further include, on the basis of the embodiment shown in fig. 4:
a second adding unit 306, configured to add, after the second display unit 305 displays the serial numbers of the problem items at the positions of the medical record problem items, related audit information of the medical record problem items to a preset problem item list, and store the focus coordinates of the medical record problem items, where the related audit information added to the problem item list includes the serial numbers of the problem items, and the serial numbers of the problem items are linked with the focus coordinates.
The related auditing information of the medical record question item can comprise: the problem item serial number, the medical record auditor, the auditing time, the medical record problem item and the auditing opinion content, and the like.
In summary, the electronic medical record auditing device disclosed by the invention acquires the focus coordinate of the medical record problem item when an auditing instruction of the medical record problem item is detected, displays the auditing suggestion frame at the position of the focus coordinate, adds the auditing suggestion content into the auditing suggestion frame after acquiring the auditing suggestion content aiming at the medical record problem item, and displays the problem item sequence number at the position of the medical record problem item. Because the invention displays the review opinion frame at the focus coordinate position of the medical record question item, so as to add the review opinion content and express the medical record question item by the question item serial number, the medical record writer can clearly see the distribution and the quantity of all the medical record question items. Meanwhile, all medical record problem items are added to the problem item list, and the problem item serial numbers in the problem item list are linked with the focus coordinates of the corresponding medical record problem items, so that when a certain row in the problem item list is selected, the position of the corresponding medical record problem item can be directly positioned according to the focus coordinates corresponding to the medical record problem items in the row, the speed of searching the medical record problem items is increased, and the occurrence of modification errors caused by positioning errors of the medical record problem items is effectively avoided.
In addition, compared with the traditional scheme, all medical record auditing opinions are descriptive characters, so that the auditing opinions of all medical record problem items are not structurally stored, and the modification opinions of all medical record problem items are not structurally stored, so that auditing data are inconvenient to trace and analyze.
In order to further optimize the above embodiment, the electronic medical record auditing apparatus may further include:
a judging unit 307, configured to judge whether there are any unverified medical record problem items;
a sending unit 308, configured to send the checked electronic medical record to the client of the medical record writer if the determining unit 307 determines that the electronic medical record is not checked.
When the judging unit 307 judges yes, the first acquiring unit 301 is executed.
It can be understood that after the electronic medical record after being checked is sent to the client of the medical record writer, the medical record writer can modify and perfect the electronic medical record according to the checking opinion content of each medical record problem item in the electronic medical record, so that the modified electronic medical record meets the medical record writing standard.
Therefore, in order to further optimize the embodiment, the invention also discloses a process for modifying the electronic medical record by a medical record writer.
On the basis of the foregoing embodiment, the electronic medical record auditing apparatus may further include:
a third obtaining unit, configured to obtain, when a modification instruction for a medical record question item in the question item list is detected, a target question item sequence number and a target focus coordinate of the medical record question item to be modified;
in practical application, when a medical record writer needs to modify a certain medical record question item in the question item list, the medical record writer can generate a modification instruction by double-clicking the row of the medical record question item to be selected.
The positioning unit is used for positioning the current electronic medical record interface to the position of the medical record problem item to be modified according to the sequence number of the target problem item and the target focus coordinate;
in practical application, in order to facilitate a medical record writer to quickly find the position of a medical record item to be modified, the sequence number of a target problem item of the medical record item to be modified can be highlighted, and the sequence number of the target problem item can be moved to the center of a screen.
A fourth obtaining unit, configured to obtain modification content for the medical record question item to be modified;
and the third adding unit is used for adding the relevant modification information of the medical record question item to be modified into the question item list.
Wherein the relevant modification information includes: the modification content, the medical record modification time, the medical record modifier and the medical record modification state and the like.
Specifically, the relevant modification information can be added to the row of the medical record question item to be modified in the question item list.
In summary, the electronic medical record auditing device disclosed by the invention can generate an amendment instruction by selecting the row of the medical record problem item after the electronic medical record after auditing is sent to the client of the medical record writer, acquire the sequence number and the target focus coordinate of the target problem item of the medical record problem item to be amended, position the current electronic medical record interface to the position of the medical record problem item to be amended according to the sequence number and the target focus coordinate of the target problem item, namely amend the medical record problem item to be amended, and add the relevant amendment information of the medical record problem item to be amended into the problem item list. According to the invention, the examination information of the medical record examiner and the modification information of the medical record writer are both stored in the problem item list, so that the structured storage of the examination information and the modification information is realized, and the statistical analysis of the medical record is conveniently and rapidly carried out.
It should be noted that, for the specific working principle of each component in the device embodiment, please refer to the corresponding part of the method embodiment, which is not described herein again.
Finally, it should also be noted that, herein, relational terms such as first and second, and the like may be used solely to distinguish one entity or action from another entity or action without necessarily requiring or implying any actual such relationship or order between such entities or actions. Also, the terms "comprises," "comprising," or any other variation thereof, are intended to cover a non-exclusive inclusion, such that a process, method, article, or apparatus that comprises a list of elements does not include only those elements but may include other elements not expressly listed or inherent to such process, method, article, or apparatus. Without further limitation, an element defined by the phrase "comprising an … …" does not exclude the presence of other identical elements in a process, method, article, or apparatus that comprises the element.
The embodiments in the present description are described in a progressive manner, each embodiment focuses on differences from other embodiments, and the same and similar parts among the embodiments are referred to each other.
The previous description of the disclosed embodiments is provided to enable any person skilled in the art to make or use the present invention. Various modifications to these embodiments will be readily apparent to those skilled in the art, and the generic principles defined herein may be applied to other embodiments without departing from the spirit or scope of the invention. Thus, the present invention is not intended to be limited to the embodiments shown herein but is to be accorded the widest scope consistent with the principles and novel features disclosed herein.
Claims (13)
1. An electronic medical record auditing method is characterized by comprising the following steps:
when an auditing instruction of a medical record question item is detected, acquiring a focus coordinate of the medical record question item;
displaying an audit opinion frame at the position of the focus coordinate;
acquiring the auditing opinion content aiming at the medical record problem item;
adding the audit opinion content into the audit opinion frame, and storing the audit opinion frame added with the audit opinion content;
and displaying the sequence number of the question item at the position of the medical record question item.
2. The method as claimed in claim 1, wherein the audit comment frame is divided into three parts of upper, middle and lower parts, the upper part is a commonly used comment description button arranged in a distribution, the middle part is a comment input text box, and the lower part is a confirm button and a cancel button.
3. The method according to claim 2, wherein the review opinion content is generated by a medical record reviewer clicking a common opinion description button corresponding to the review opinion content, or is a text content directly input by the medical record reviewer in the review opinion box.
4. The method according to claim 2, wherein the obtaining of review opinion content for the medical record question item specifically comprises:
when a selection instruction of the frequently-used opinion description button is detected, determining the selected frequently-used opinion description button as a target frequently-used opinion description button;
and searching the corresponding audit opinion content corresponding to the target common opinion description button from the corresponding relationship between the pre-stored common opinion description button and the audit opinion content.
5. The method of claim 1, further comprising, after the step of displaying the question item ordinal number at the location of the medical record question item:
and adding related audit information of the medical record problem items into a preset problem item list, and storing the focus coordinates of the medical record problem items, wherein the related audit information added to the problem item list comprises the problem item serial numbers, and the problem item serial numbers are linked with the focus coordinates.
6. The method of claim 5, further comprising:
judging whether an unverified medical record problem item exists or not;
and if not, sending the checked electronic medical record to a client of a medical record writer.
7. The method of claim 6, further comprising:
when a modification instruction of the medical record problem items in the problem item list is detected, acquiring a target problem item sequence number and a target focus coordinate of the medical record problem item to be modified;
positioning the current electronic medical record interface to the position of the medical record problem item to be modified according to the sequence number of the target problem item and the target focus coordinate;
acquiring the modification content of the medical record problem item to be modified;
and adding the relevant modification information of the medical record question item to be modified into the question item list.
8. An electronic medical record auditing device, characterized by comprising:
the first acquisition unit is used for acquiring the focus coordinate of the medical record question item when an auditing instruction of the medical record question item is detected;
the first display unit is used for displaying an audit opinion frame at the position of the focus coordinate;
the second acquisition unit is used for acquiring the auditing opinion content aiming at the medical record question item;
the first adding unit is used for adding the audit opinion content into the audit opinion frame and storing the audit opinion frame added with the audit opinion content;
and the second display unit is used for displaying the sequence number of the question item at the position of the medical record question item.
9. The apparatus of claim 8, wherein the audit comment frame is divided into three parts, an upper part, a middle part and a lower part, the upper part is a commonly used comment description button arranged in a distribution, the middle part is a comment input text box, and the lower part is a confirm button and a cancel button.
10. The apparatus according to claim 9, wherein the second obtaining unit is specifically configured to:
when a selection instruction of the frequently-used opinion description button is detected, determining the selected frequently-used opinion description button as a target frequently-used opinion description button;
and searching the corresponding audit opinion content corresponding to the target common opinion description button from the corresponding relationship between the pre-stored common opinion description button and the audit opinion content.
11. The apparatus of claim 8, further comprising:
and the second adding unit is used for adding related auditing information of the medical record question items to a preset question item list after the second display unit displays the question item serial numbers at the positions of the medical record question items, and storing the focus coordinates of the medical record question items, wherein the related auditing information added to the question item list comprises the question item serial numbers, and the question item serial numbers are linked with the focus coordinates.
12. The apparatus of claim 11, further comprising:
the judging unit is used for judging whether an unverified medical record problem item exists or not;
and the sending unit is used for sending the checked electronic medical record to the client of the medical record writer under the condition that the judging unit judges that the electronic medical record is not checked.
13. The apparatus of claim 12, further comprising:
a third obtaining unit, configured to obtain, when a modification instruction for a medical record question item in the question item list is detected, a target question item sequence number and a target focus coordinate of the medical record question item to be modified;
the positioning unit is used for positioning the current electronic medical record interface to the position of the medical record problem item to be modified according to the sequence number of the target problem item and the target focus coordinate;
a fourth obtaining unit, configured to obtain modification content for the medical record question item to be modified;
and the third adding unit is used for adding the relevant modification information of the medical record question item to be modified into the question item list.
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