CN111883224A - Electronic medical record processing method and device, computer equipment and storage medium - Google Patents
Electronic medical record processing method and device, computer equipment and storage medium Download PDFInfo
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- 238000012423 maintenance Methods 0.000 abstract description 26
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- G16H15/00—ICT specially adapted for medical reports, e.g. generation or transmission thereof
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- G—PHYSICS
- G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H10/00—ICT specially adapted for the handling or processing of patient-related medical or healthcare data
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Abstract
The application relates to a processing method and device of an electronic medical record, computer equipment and a storage medium. The method comprises the following steps: acquiring custom configuration information corresponding to a patient identifier, and generating an element column of an electronic medical record summary table corresponding to the patient identifier according to the custom configuration information; acquiring corresponding historical electronic medical record data according to the patient identification; and searching the record data corresponding to each element from the historical electronic medical record data according to each element in the electronic medical record summary table, and storing the corresponding record data under each element column in the electronic medical record summary table. By adopting the method, the treatment information of a certain patient in the treatment system can be comprehensively summarized without manual inquiry processing, the complex operation flow and the consumption of a large amount of time in the traditional mode are effectively avoided, the operation flow for maintaining the electronic medical record is greatly simplified, the maintenance efficiency of the electronic medical record is effectively improved, and convenience is provided for users.
Description
Technical Field
The present application relates to the field of computer technologies, and in particular, to a method and an apparatus for processing an electronic medical record, a computer device, and a storage medium.
Background
With the development of computer technology and the coming of the 5G era, the appearance of the Internet brings great convenience to modern life, and more organizations adopt a unified online business information management platform to uniformly manage all resources and information of the organizations. In the traditional medical field, nurses can fill corresponding treatment records in a treatment system according to the medical orders of each patient. Due to the particularity of the treatment system, the treatment items of the same medical advice and the corresponding treatment templates are different, so the medical advice of each patient needs to be split to obtain a plurality of corresponding medical advice orders. The electronic medical record applied to the treatment system can display all treatment execution records under each medical advice separation.
However, in the current maintenance method of the electronic medical record information, only checking all treatment information under each medical advice separate order can be supported, and complete treatment information cannot be provided, when a nurse fills in treatment information of a patient at a PC, the nurse needs to refer to the previous treatment information for filling, if the nurse wants to know the previous treatment information, the nurse needs to quit the current editing interface, search for treatment information under each previous medical advice separate order document in other interfaces of the treatment system, and reopen the editing interface for filling after searching, which needs to spend a lot of manpower and energy for filling, and needs to repeat a lot of complicated operations, thereby resulting in low maintenance efficiency of the electronic medical record information.
Disclosure of Invention
In view of the above, it is desirable to provide a method, an apparatus, a computer device, and a storage medium for processing an electronic medical record, which can improve the maintenance efficiency of the electronic medical record.
A method of processing an electronic medical record, the method comprising:
acquiring custom configuration information corresponding to a patient identifier, and generating an element column of an electronic medical record summary table corresponding to the patient identifier according to the custom configuration information;
acquiring corresponding historical electronic medical record data according to the patient identification;
according to each element in the electronic medical record summary table, searching the record data corresponding to each element from the historical electronic medical record data;
and storing corresponding record data under each element column in the electronic medical record summary table.
In one embodiment, the obtaining of the user-defined configuration information corresponding to the patient identifier and the generating of the element column of the electronic medical record summary table corresponding to the patient identifier according to the user-defined configuration information include:
displaying a plurality of configuration items on a configuration interface;
acquiring a selected configuration item from the plurality of configuration items, and taking the selected configuration item as user-defined configuration information corresponding to the patient identifier;
and generating an element column of the electronic medical record summary table corresponding to the patient identification according to the element name corresponding to the selected configuration item.
In one embodiment, the presenting a plurality of configuration items on the configuration interface includes:
the method comprises the steps of obtaining a configuration template type, and displaying a plurality of configuration items corresponding to the configuration template type on a configuration interface.
In one embodiment, the searching, according to each element in the electronic medical record summary table, record data corresponding to each element from the historical electronic medical record data includes:
acquiring a first element code corresponding to an element from a main table of the historical electronic medical record data;
acquiring second element codes corresponding to elements in the electronic medical record summary table;
matching the second element code with the first element code, and acquiring an element value corresponding to the first element code which is the same as the second element code when the second element code is the same as the first element code;
the storing of the corresponding record data under each element in the electronic medical record summary table comprises:
and storing the element value corresponding to the first element code which is the same as the second element code under the element corresponding to the second element code.
In one embodiment, the storing the element value corresponding to the first element code which is the same as the second element code under the element corresponding to the second element code comprises:
and when at least two element values corresponding to the second element code which is the same as the second element code exist, storing the at least two element values under the element corresponding to the second element code according to the time sequence.
In one embodiment, the method further comprises:
acquiring the display attribute of the selected configuration item; the display attribute comprises visible or invisible;
and determining an element column of the electronic medical record summary table corresponding to the patient identification according to the display attribute of the configuration item.
In one embodiment, after generating the element column of the electronic medical record summary table corresponding to the patient identifier according to the custom configuration information, the method further includes:
acquiring newly added or deleted configuration items input by a user;
and dynamically adjusting element columns in the electronic medical record summary table corresponding to the patient identification according to the element names corresponding to the configuration items.
An apparatus for processing an electronic medical record, the apparatus comprising:
the generating module is used for acquiring custom configuration information corresponding to the patient identifier and generating an element column of an electronic medical record summary table corresponding to the patient identifier according to the custom configuration information;
the acquisition module is used for acquiring corresponding historical electronic medical record data according to the patient identification;
the searching module is used for searching the record data corresponding to each element from the historical electronic medical record data according to each element in the electronic medical record summary table;
and the storage module is used for storing corresponding record data under each element column in the electronic medical record summary table.
A computer device comprising a memory and a processor, the memory storing a computer program, the processor implementing the following steps when executing the computer program:
acquiring custom configuration information corresponding to a patient identifier, and generating an element column of an electronic medical record summary table corresponding to the patient identifier according to the custom configuration information;
acquiring corresponding historical electronic medical record data according to the patient identification;
according to each element in the electronic medical record summary table, searching the record data corresponding to each element from the historical electronic medical record data;
and storing corresponding record data under each element column in the electronic medical record summary table.
A computer-readable storage medium, on which a computer program is stored which, when executed by a processor, carries out the steps of:
acquiring custom configuration information corresponding to a patient identifier, and generating an element column of an electronic medical record summary table corresponding to the patient identifier according to the custom configuration information;
acquiring corresponding historical electronic medical record data according to the patient identification;
according to each element in the electronic medical record summary table, searching the record data corresponding to each element from the historical electronic medical record data;
and storing corresponding record data under each element column in the electronic medical record summary table.
According to the processing method, the processing device, the computer equipment and the storage medium of the electronic medical record, the element column of the electronic medical record summary table corresponding to the patient identifier is generated according to the user-defined configuration information by acquiring the user-defined configuration information corresponding to the patient identifier. Acquiring corresponding historical electronic medical record data according to the patient identification, searching the record data corresponding to each element from the historical electronic medical record data according to each element in the electronic medical record summary table, and storing the corresponding record data under each element column in the electronic medical record summary table. Therefore, when the electronic medical record of the patient needs to be maintained, the element column of the electronic medical record summary table corresponding to the patient identifier is generated according to the custom configuration information by acquiring the custom configuration information corresponding to the patient identifier. Meanwhile, corresponding historical electronic medical record data are obtained according to the patient identification, the record data corresponding to each element are searched from the historical electronic medical record data, the corresponding record data are stored under each element column in the electronic medical record summary table, dynamic adjustment of the element columns in the electronic medical record summary table and automatic summary of the electronic medical record information can be achieved, manual query and processing are not needed, tedious operation processes and consumption of a large amount of time in a traditional mode are effectively avoided, the treatment information of a certain patient in a treatment system can be comprehensively summarized by matching each element in the electronic medical record summary table with the element in the historical electronic medical record data, the operation processes of electronic medical record maintenance are greatly simplified, maintenance efficiency of the electronic medical record is effectively improved, and convenience is provided for users.
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FIG. 1 is a diagram of an application environment of a method for processing an electronic medical record in an embodiment;
FIG. 2 is a flow diagram illustrating a method for processing an electronic medical record according to one embodiment;
FIG. 3 is a flowchart illustrating the steps of generating an element column of an electronic medical record summary table corresponding to a patient identifier based on custom configuration information, in one embodiment;
FIG. 4 is a flowchart illustrating a method for processing an electronic medical record according to another embodiment;
FIG. 5 is a flowchart illustrating the step of dynamically adjusting columns of elements in an electronic medical record summary table corresponding to patient identification, according to one embodiment;
FIG. 6 is a block diagram of an apparatus for processing an electronic medical record according to one embodiment;
FIG. 7 is a diagram illustrating an internal structure of a computer device according to an embodiment.
Detailed Description
In order to make the objects, technical solutions and advantages of the present application more apparent, the present application is described in further detail below with reference to the accompanying drawings and embodiments. It should be understood that the specific embodiments described herein are merely illustrative of the present application and are not intended to limit the present application.
The processing method of the electronic medical record provided by the application can be applied to the application environment shown in fig. 1. Wherein the terminal 102 communicates with the server 104 via a network. The terminal 102 can obtain the corresponding configuration information and the historical medical record data from the server 104 by sending a request to the server 104. The terminal 102 obtains the custom configuration information corresponding to the patient identifier from the server 104, and the terminal 102 generates an element column of an electronic medical record summary table corresponding to the patient identifier according to the custom configuration information. The terminal 102 obtains corresponding historical electronic medical record data from the server 104 according to the patient identification. The terminal 102 searches the record data corresponding to each element from the historical electronic medical record data according to each element in the electronic medical record summary table, and the terminal 102 stores the corresponding record data under each element column in the electronic medical record summary table. The terminal 102 may be, but not limited to, various personal computers, notebook computers, smart phones, tablet computers, and portable wearable devices, and the server 104 may be implemented by an independent server or a server cluster formed by a plurality of servers.
In an embodiment, as shown in fig. 2, a method for processing an electronic medical record is provided, which is described by taking the method as an example of being applied to the terminal in fig. 1, and includes the following steps:
The terminal may communicate with the server over a network and remain online over a network communication connection. For example, different types of terminal devices may be transmitted using the operator-stable network after connecting to the wireless network or the local area network. In the current medical field, a nurse can fill corresponding treatment information in a treatment system according to an order prescribed by a doctor for each patient. The treatment system refers to a treatment information management system, can be a management system of various types of treatment information established by medical institutions according to different departments, and has important significance for realizing the planning, traceability and convenience of a treatment process. Staff such as doctors and nurses can input medical record information corresponding to different patients by logging in a treatment system interface, and electronic medical record information of different patients can be stored in the system. The electronic medical record is a control which is embedded in software such as a treatment system and is used for a doctor or a nurse to edit and view treatment documents in the patient's visit records. The electronic medical records can comprise the information of the previous visits and the treatment information of different patients. Due to the particularity of the treatment system, treatment templates corresponding to treatment items of the same medical advice may be different, so the medical advice of each patient needs to be split to obtain a plurality of corresponding medical advice orders. The staff can establish the electronic medical record that different patients correspond in the treatment system, can show all treatment execution records of patient under each advice minute in the electronic medical record interface. Doctors or nurses can log in the interface of the treatment system by using different terminal devices, the different terminal devices can send message requests to the server, the server searches corresponding configuration information from the database according to the received message requests, and the server sends the inquired configuration information to the corresponding terminals.
Specifically, the treatment system page may be displayed in the terminal device through a web application, and the doctor or the nurse may browse through a main page of the displayed treatment information system after logging in the treatment system, where the web application may be a browser or other application program (e.g., a treatment system application, a treatment information local area network, etc.) that may display the content of the page. After the staff logs in the treatment system, corresponding operations can be performed in a treatment system page displayed by the display according to the current medical advice information of the patient. For example, when a worker needs to fill in corresponding electronic medical record data according to the order information of the current patient, the worker can create a task of an electronic medical record summary table corresponding to the patient through a triggering operation, and meanwhile, the worker can also add configuration information corresponding to the electronic medical record summary table in a user-defined manner. Further, when the staff initiates the creation task through the triggering operation, the terminal may obtain the configuration information corresponding to the template identifier of the summary table from the server according to the template identifier corresponding to the electronic medical record summary table in the creation task, and the terminal may generate the element column of the electronic medical record summary table corresponding to the patient identifier according to the configuration information. The configuration information refers to template information, configuration table information and attribute information corresponding to the configuration table, which are configured in advance according to different types of treatment information, and the user can set customized configuration information corresponding to a plurality of pieces of dimension information according to pieces of dimension information such as treatment rule information, treatment part information, treatment time and treatment strategies of different treatment methods. The configuration information may include medical record template identifiers, element names, element codes, attribute information of configuration item information, configuration rules, configuration modes, and the like corresponding to different medical record data. The electronic medical record summary table is used for summarizing all treatment information under each medical order corresponding to each patient to obtain comprehensive and complete electronic medical record information of each patient. The electronic medical record summary table can comprise a plurality of different types of symptoms corresponding to the patient identification, different types of treatment information and the like. For example, when a worker enters a treatment document interface for the first time through a triggering operation, a user can read all configurable basic data corresponding to the created electronic medical record summary list, and the user can set custom configuration information corresponding to the summary list to be created according to the requirements of maintaining different medical record data. The configuration information of the electronic medical record summary table corresponding to different medical record templates is pre-stored in the database, the terminal can acquire corresponding custom configuration information from the database according to different medical record template identifiers, and the terminal generates an element column of the electronic medical record summary table corresponding to the patient identifier according to the acquired custom configuration information. The element column refers to a column of tables generated in the summary list according to elements contained in different types of summary list templates. The element is a basic component of the electronic medical record template, is an abstract expression of a value filled in a form and consists of a plurality of attributes such as an element name, an element code, an element value, an affiliated list and the like. The electronic medical record template refers to an electronic form made according to a user paper form, and similar to a document, column header information of the summary template can be stored in configuration information, and information of which element is in each column in the summary table is indicated. For example, the staff needs to create a skin treatment data summary table corresponding to a certain patient, the terminal may obtain corresponding custom configuration information from the database according to the skin treatment medical record template identifier, and the terminal generates an element column of the skin treatment summary table corresponding to the patient identifier according to the obtained custom configuration information, where, if the custom configuration information may include elements such as a tartaric acid skin-activating treatment, a treatment site, a tartaric acid concentration, and a treatment time, the terminal may generate an element column corresponding to the skin treatment summary table corresponding to the patient identifier according to the obtained element name in the configuration information, and the element column name in the skin treatment summary table corresponding to the patient identifier may include 4 column names of the tartaric acid skin-activating treatment, the treatment site, the tartaric acid concentration, and the treatment time.
And step 204, acquiring corresponding historical electronic medical record data according to the patient identification.
And after the terminal generates an element column of the electronic medical record summary table corresponding to the patient identifier according to the user-defined configuration information, the terminal acquires corresponding historical electronic medical record data according to the patient identifier. Specifically, the terminal can send a request to the server according to the patient identifier, and the server searches for the corresponding historical electronic medical record data in the database according to the request and sends the searched historical electronic medical record data corresponding to the patient identifier to the corresponding terminal. The historical electronic medical record data refers to the previous treatment information and treatment information of different patients, and the corresponding treatment information and treatment information are stored under each medical advice division, so that the server can inquire the treatment information corresponding to the patient identification from the database according to different treatment document numbers.
And step 206, searching the record data corresponding to each element from the historical electronic medical record data according to each element in the electronic medical record summary table.
After the terminal acquires the corresponding historical electronic medical record data according to the patient identification, the terminal can search the record data corresponding to each element from the historical electronic medical record data according to each element in the electronic medical record summary table. The element is a basic component of the electronic medical record template, is an abstract expression of a value filled in a form and consists of a plurality of attributes such as an element name, an element code, an element value, an affiliated list and the like. Different elements can be contained in different electronic medical record data summarization tables, for example, the element columns corresponding to the skin treatment summarization table can comprise elements such as the skin activating treatment, the treatment part, the concentration of the tartaric acid, the treatment time and the like. Specifically, the terminal can search the record data corresponding to each element from the historical electronic medical record data according to each element in the skin treatment summary table, for example, the record data corresponding to the tartaric acid skin-activating treatment corresponding to the patient identification is the recorded data corresponding to the medical advice diagnosis result combined type leprosy, the record data corresponding to the treatment part is the chest, the concentration of the tartaric acid is 20% and the treatment time is 09:56: 08.
And step 208, storing corresponding record data under each element column in the electronic medical record summary table.
After the terminal searches the record data corresponding to each element from the historical electronic medical record data according to each element in the electronic medical record summary table, the terminal can store the corresponding record data under each element column in the electronic medical record summary table. For example, the terminal may search, according to each element in the skin treatment summary table, the record data corresponding to each element from the historical electronic medical record data, for example, the record data corresponding to the tartaric acid skin-activating treatment corresponding to the patient identifier is the type leprosy combined with the medical advice diagnosis result, the record data corresponding to the treatment part is the chest, the concentration of the tartaric acid is 20% and the treatment time is 09:56: 08. Further, the terminal assigns the record data corresponding to each element to each corresponding element column in the electronic medical record summary table, that is, the terminal stores the corresponding record data under each element column in the electronic medical record summary table.
In the traditional treatment system, when the electronic medical record information needs to be maintained, the system can only support to check all treatment information under each medical advice minute order and cannot provide complete treatment information corresponding to each patient, when a nurse maintains the electronic medical record information of the patient at a PC (personal computer) end, the nurse needs to refer to the previous treatment information for filling, if the nurse wants to know the previous treatment information, the nurse needs to quit the current editing interface, the treatment information under each conventional medical advice separate order document is searched in other interfaces of the treatment system, the editing interface is opened again for filling after the search, only limited treatment information corresponding to each medical advice separate order can be displayed in each inquiry, all types of treatment information of the patient can not be provided directly, a large amount of manpower and energy are needed for maintenance, meanwhile, a large amount of complicated operations need to be repeated, so that the maintenance efficiency of the electronic medical record information is low.
In this embodiment, the element column of the electronic medical record summary table corresponding to the patient identifier is generated according to the custom configuration information by acquiring the custom configuration information corresponding to the patient identifier. Acquiring corresponding historical electronic medical record data according to the patient identification, searching the record data corresponding to each element from the historical electronic medical record data according to each element in the electronic medical record summary table, and storing the corresponding record data under each element column in the electronic medical record summary table. Therefore, when the electronic medical record of the patient needs to be maintained, the element column of the electronic medical record summary table corresponding to the patient identifier is generated according to the custom configuration information by acquiring the custom configuration information corresponding to the patient identifier. Meanwhile, corresponding historical electronic medical record data are obtained according to the patient identification, the record data corresponding to each element are searched from the historical electronic medical record data, the corresponding record data are stored under each element column in the electronic medical record summary table, dynamic adjustment of the element columns in the electronic medical record summary table and automatic summary of the electronic medical record information can be achieved, manual query and processing are not needed, tedious operation processes and consumption of a large amount of time in a traditional mode are effectively avoided, the treatment information of a certain patient in a treatment system can be comprehensively summarized by matching each element in the electronic medical record summary table with the element in the historical electronic medical record data, the operation processes of electronic medical record maintenance are greatly simplified, maintenance efficiency of the electronic medical record is effectively improved, and convenience is provided for users.
In one embodiment, presenting the plurality of configuration items at the configuration interface includes obtaining a configuration template type, and presenting a plurality of configuration items corresponding to the configuration template type at the configuration interface.
When the staff initiates the creation task through the triggering operation, the terminal can obtain the configuration information corresponding to the summary table identifier from the server according to the summary table identifier corresponding to the electronic medical record summary table in the creation task, and the terminal can generate the element column of the electronic medical record summary table corresponding to the patient identifier according to the configuration information. Specifically, when a user enters the treatment document maintenance interface for the first time through a trigger operation, the user can read all configurable basic data corresponding to the creation of the electronic medical record summary table, that is, the terminal can display a plurality of configuration items corresponding to the electronic medical record summary table in the configuration interface. The user can select template information corresponding to the summary list to be created through a triggering operation according to the requirements of maintaining different medical record data, for example, when the user enters a treatment document maintenance interface for the first time through the triggering operation, the user can select the template information corresponding to the summary list to be created as a skin treatment template through the triggering operation, and then the terminal can acquire the configuration template type selected by the user and display a plurality of configuration item information corresponding to the configuration template type on the configuration interface. The user can read all configurable basic data corresponding to the creation of the skin treatment summary table, that is, the terminal can display a plurality of configuration items corresponding to the skin treatment template in the configuration interface, such as element column names, display attribute information, column sorting and other configuration item information. The plurality of configuration items presented in the configuration interface may include recording time, pain location, skin color, light type, light source, energy density, awareness, special case, signature information, and the like. The user can select the 6 configuration item information of recording time, pain parts, skin colors, light types, light sources and energy densities by triggering operation according to the requirements of maintaining medical record data of different patients, so that the terminal can acquire the configuration item selected by the user from the multiple configuration items, and the terminal takes the selected configuration item as the self-defined configuration information corresponding to the patient identifier. In addition, when the user needs to maintain medical record data corresponding to a plurality of different medical advice orders corresponding to the patient identification, the user can switch the medical record template through triggering operation, that is, the user can select different types of template information corresponding to the summary list to be created through triggering operation, such as a skin treatment template, a photodynamic treatment template and the like. The user can set the configuration information corresponding to different templates in the maintenance interface in advance, for example, the user can set different element names and element codes corresponding to different templates in a user-defined manner, so that the terminal can collect all treatment information of the patient according to different element information corresponding to different templates configured by the user in advance. The configuration table may include a medical record configuration template ID, an element code, an element name, and the like. The terminal can search corresponding self-defined configuration information from the database according to the medical record template ID corresponding to the summary table which is created as required. For example, the name of the configuration Table is Table _ pz, the name of the medical record template ID field is TpId, and the template ID value corresponding to the summary Table that needs to be created currently is 123, then the terminal may query the corresponding self-defined configuration information from the database, and the database query statement is select from Table _ pz where TpId is '123'. Therefore, the user can decide the column names of the summary list by himself or can perform customized column sorting, specific summary data concerned by each user can be generated according to customized configuration information, the system can automatically classify and summarize treatment information of each patient according to element codes in historical medical record data, manual inquiry is not needed for processing, electronic medical record information corresponding to different templates can be automatically summarized, comprehensive summary of the treatment information of the patients in the treatment system can be realized, and complete treatment information is provided.
In one embodiment, as shown in fig. 3, the step of obtaining the custom configuration information corresponding to the patient identifier and generating the element column of the electronic medical record summary table corresponding to the patient identifier according to the custom configuration information includes:
And step 306, generating an element column of the electronic medical record summary table corresponding to the patient identification according to the element name corresponding to the selected configuration item.
When the staff initiates the creation task through the triggering operation, the terminal can obtain the configuration information corresponding to the summary table identifier from the server according to the summary table identifier corresponding to the electronic medical record summary table in the creation task, and the terminal can generate the element column of the electronic medical record summary table corresponding to the patient identifier according to the configuration information. Specifically, when a user enters the treatment document maintenance interface for the first time through a trigger operation, the user can read all configurable basic data corresponding to the creation of the electronic medical record summary table, that is, the terminal can display a plurality of configuration items corresponding to the electronic medical record summary table in the configuration interface. The user can select the user-defined configuration information corresponding to the summary list to be created through triggering operation according to the requirements of maintaining different medical record data. For example, when the user enters the treatment document maintenance interface for the first time through a trigger operation, the user may read all configurable basic data corresponding to the creation of the skin treatment summary table, that is, the terminal may present, in the configuration interface, a plurality of configuration items corresponding to the skin treatment summary table, such as element column names, display attribute information, column ordering, and other configuration item information. The plurality of configuration items presented in the configuration interface may include recording time, pain location, skin color, light type, light source, energy density, awareness, special case, signature information, and the like. The user can select the information of 6 configuration items including recording time, pain parts, skin colors, light types, light sources and energy densities through triggering operation according to the requirements of maintaining different medical record data, so that the terminal can acquire the configuration item selected by the user from the multiple configuration items, and the terminal takes the selected configuration item as the self-defined configuration information corresponding to the patient identifier. Further, the terminal generates an element column of the electronic medical record summary table corresponding to the patient identifier according to the element name corresponding to the selected configuration item, that is, the terminal generates an element column of the skin treatment summary table corresponding to the patient identifier according to the element name corresponding to the selected configuration item, so that the element column in the skin treatment summary table corresponding to the patient identifier may include 6 columns of recording time, a pain part, a skin color, a light type, a light source, and an energy density, and the terminal uses the element name as the name of each column, that is, the 6 column names are respectively the recording time, the pain part, the skin color, the light type, the light source, and the energy density. The terminal can also create column names corresponding to the sequence according to the sequence corresponding to the configuration items selected by the user. For example, if the element corresponding to the sequence number 1 is recording time, the terminal may create a column name of the first column table in the summary table as recording time, and the terminal may create a corresponding column sequence number from the element sequence number 1 according to the sequence number corresponding to the selected element. Therefore, the user can decide the column names of the summary list by himself or herself, the user-defined column sorting can be carried out, corresponding summary data can be generated according to user-defined configuration information, element columns in the electronic medical record summary list can be dynamically adjusted, electronic medical record information can be automatically summarized, manual inquiry is not needed for processing, tedious operation procedures and consumption of a large amount of time in a traditional mode are effectively avoided, the maintenance efficiency of the electronic medical records is effectively improved, and convenience is provided for the user.
In an embodiment, as shown in fig. 4, a method for processing an electronic medical record is provided, which is described by taking the method as an example of being applied to the terminal in fig. 1, and includes the following steps:
And step 404, acquiring corresponding historical electronic medical record data according to the patient identification.
And 406, acquiring a first element code corresponding to the element from the main table of the historical electronic medical record data.
And step 408, acquiring second element codes corresponding to the elements in the electronic medical record summary table.
And step 410, matching the second element code with the first element code, and acquiring an element value corresponding to the first element code which is the same as the second element code when the second element code is the same as the first element code.
When the staff initiates the creation task through the triggering operation, the terminal can obtain the configuration information corresponding to the template identifier of the summary table from the server according to the template identifier corresponding to the electronic medical record summary table in the creation task, and the terminal can generate the element column of the electronic medical record summary table corresponding to the patient identifier according to the configuration information. Further, the terminal acquires corresponding historical electronic medical record data from the database according to the patient identifier, the historical electronic medical record data can include various types of treatment information corresponding to the patient identifier, and all values filled in the medical record document and elements to which the values belong are recorded in the treatment information. For example, the treatment information corresponding to one medical order sub-order includes a main treatment record table and a detailed treatment record table, the information of the main table includes a unique identifier of the main table, a treatment item, a treatment record name, a creator, creation time, and the like, and the information of the sub-table, that is, the information of the detailed treatment record table includes a unique identifier of the sub-table, a corresponding identifier of the main table, an element code, an element value, an element identifier, and the like. The terminal can search the corresponding treatment document identification from the historical medical record data according to the template identification of the electronic medical record summary table corresponding to the patient identification, search the main table identification information corresponding to the treatment main table from different treatment document identifications, and further inquire the elements matched with the element columns in the electronic medical record summary table from a plurality of treatment main table identifications. For example, the terminal may obtain the element codes corresponding to the elements in the skin treatment summary table, that is, the terminal may obtain the element code corresponding to the recording time of the first row element column in the skin treatment summary table as 100551, the element code corresponding to the pain part of the second row element column as 200661, the element code corresponding to the skin color of the third row element column as skin, the element code corresponding to the light type of the fourth row element column as 3004, the element code corresponding to the light source of the fifth row element column as hr52.01.f500, and the element code corresponding to the energy density of the sixth row element column as hr52.01.f 501. The terminal can mark the element codes acquired from the skin treatment summary table as second element codes, and the terminal searches through a plurality of main tables in the history medical record data corresponding to the patient identifier from the element codes corresponding to the first row of element columns, and searches for the first element codes matched with the second element codes. For example, the terminal may search, according to the skin treatment template identifier in the skin treatment summary table, a corresponding treatment document identifier from the historical medical record data, that is, the terminal searches, from the historical medical record data, a treatment document identifier corresponding to the skin treatment template identifier of the patient, further searches, in the searched treatment document identifier, element code information corresponding to each treatment master table, and the terminal searches element information in the plurality of treatment master tables in a traversing manner, that is, the terminal may obtain, from the plurality of master tables of the historical electronic medical record data, an element code corresponding to each element, and the terminal may mark the element code obtained from the historical electronic medical record data as the first code. When the terminal finds the first code which is the same as the second element code HR52.01.F500 in the historical medical record data, the terminal obtains that the element value corresponding to the element code HR52.01.F500 in the historical medical record data is 2.5, the element value is the record data corresponding to the element column, and the terminal stores the element value 2.5 in the table corresponding to the light source of the fifth column of the element column corresponding to the element code HR52.01.F500 in the skin treatment summary table. The terminal may store the element values in the historical case data in the skin treatment summary table that match the element code of each element column under the element column corresponding to the skin treatment summary table in the above-described element code matching manner. From this make can realize the element list in the dynamic adjustment electronic medical record summary table and automatic electronic medical record information that gathers, need not to handle through artifical manual inquiry, the effectual loaded down with trivial details operation flow and the consumeing of a large amount of time in having avoided traditional mode, match through each element in the electronic medical record summary table and the element in the historical electronic medical record data, can realize carrying out comprehensive gathering to certain patient's treatment information in the treatment system, very big simplification the operation flow that the electronic medical record maintained, thereby the effectual maintenance efficiency who improves the electronic medical record, it is convenient also to provide for the user simultaneously.
In one embodiment, the step of storing the value of the element corresponding to the first element code identical to the second element code to the element corresponding to the second element code comprises:
and when at least two element values corresponding to the second element code which is the same as the second element code exist, storing the at least two element values under the element corresponding to the second element code according to the time sequence.
When a user enters a treatment document maintenance interface for the first time through triggering operation, the user can read all configurable basic data corresponding to the created electronic medical record summary table, and the user can also preset self-defined configuration information such as element names, element codes and the like according to the requirements of different medical institutions. For example, the user may set in advance the element name "recording time" and the element code "Date". Then, when the terminal performs matching and summarizing information according to the element code, the terminal may acquire all the historical treatment records corresponding to the patient identifier, and traverse through whether there is data with the element code of "Date" in the historical treatment record corresponding to the patient identifier, for example, the terminal may search for a record containing the "Date" element in the historical treatment record corresponding to the patient identifier, where the element values are "2020-6-10" and "2020-5-10", and then the terminal may assign the data of "2020-5-10" and "2020-6-10" according to the time sequence below the element column corresponding to the "treatment record" in the summarizing list. Therefore, the user can acquire the summary of all medical record information corresponding to the patient identification without manual query processing, the complex operation flow and the consumption of a large amount of time in the traditional mode are effectively avoided, the operation flow for maintaining the electronic medical records is greatly simplified, the maintenance efficiency of the electronic medical records is effectively improved, and convenience is provided for the user.
In one embodiment, the method further includes a step of determining an element column of the electronic medical record summary table corresponding to the patient identifier according to the display attribute of the configuration item, and specifically includes:
acquiring the display attribute of the configuration item; the display attribute includes visible or invisible.
And determining an element column of the electronic medical record summary table corresponding to the patient identification according to the display attribute of the configuration item.
When the user enters the treatment document maintenance interface for the second time through the triggering operation, the user can read all configured information of the template corresponding to the created electronic medical record summary table, namely, the terminal can display a plurality of configuration items corresponding to the template identification of the electronic medical record summary table in the configuration interface, such as configuration item information of element column names, display attribute information, column sequencing and the like. Further, the terminal may obtain display attributes of the configuration items corresponding to the summary table template, where the display attributes include visible or invisible. And the terminal determines an element column of the electronic medical record summary table corresponding to the patient identification according to the display attribute of the configuration item. For example, the user may read all the configurable basic data corresponding to the creation of the skin treatment summary table, that is, the terminal may present a plurality of configuration items corresponding to the skin treatment template in the configuration interface, such as element column names, display attribute information, column ordering, and other configuration item information. The plurality of configuration items presented in the configuration interface may include recording time, pain location, skin color, light type, light source, energy density, awareness, special case, signature information, and the like. The user can select the 3 configuration item information of recording time, pain parts and energy density and set the corresponding display attribute to be displayable by triggering operation according to the requirements of maintaining medical record data of different patients. Wherein the display properties of the configuration items comprise visible or invisible. Further, the terminal may obtain that all display attributes of the configuration items selected by the user from the plurality of configuration items are visible, and the terminal may determine, according to the display attributes of the 3 configuration items, the element columns of the electronic medical record summary table corresponding to the patient identifier, that is, the terminal may generate, according to the information of the 3 configuration items that are visible, 3 element columns of the electronic medical record summary table corresponding to the patient identifier for display, that is, the column name of the first column may be displayed in the electronic medical record summary table corresponding to the patient identifier as the recording time, the column name of the second column is the pain part, and the column name of the third column is the energy density. Therefore, the user can decide the column names of the summary list by himself or can perform customized column sorting, specific summary data concerned by each user can be generated according to customized configuration information, manual inquiry and processing are not needed, electronic medical record information corresponding to different templates can be automatically summarized, treatment information of patients in a treatment system can be comprehensively summarized, and complete treatment information is provided.
In an embodiment, as shown in fig. 5, after generating the element column of the electronic medical record summary table corresponding to the patient identifier according to the customized configuration information, the method further includes a step of dynamically adjusting the element column in the electronic medical record summary table corresponding to the patient identifier, which specifically includes:
And step 504, dynamically adjusting element columns in the electronic medical record summary table corresponding to the patient identification according to the element names corresponding to the configuration items.
When the user enters the treatment document maintenance interface for the second time through the triggering operation, the user can directly obtain the configured self-defined configuration item information corresponding to the template information for creating the electronic medical record summary table, and the terminal generates the element column of the electronic medical record summary table corresponding to the patient identifier according to the self-defined configuration information. When a user adds or deletes an element column in the electronic medical record summary table according to the requirement of a current patient, the user can log in a treatment document maintenance interface, and input newly-added custom configuration item information or delete original configuration item information through triggering operation, for example, the user inputs the newly-added custom configuration item information as a treatment response in the treatment document maintenance interface, the terminal can obtain the newly-added configuration item information input by the user, the terminal takes the element name corresponding to the configuration item as the treatment response, and dynamically adjusts the column name of a newly-added element column in the electronic medical record summary table corresponding to the patient identifier as the treatment response. If the user inputs the light source for deleting the configuration item information in the treatment document maintenance interface, the terminal can acquire the configuration item deleting information input by the user, and the terminal dynamically adjusts the electronic medical record summary list corresponding to the patient identification to delete the corresponding light source element list according to the element name corresponding to the configuration item as the light source. From this make can be according to the information in the user's demand dynamic adjustment electronic medical record summary table, maintenance technique through the dynamic column, the element list in the dynamic adjustment electronic medical record summary table and the automatic electronic medical record information that gathers have been realized, need not to handle through artifical manual inquiry, loaded down with trivial details operation flow and the consumeing of plenty of time in the effectual traditional mode of having avoided, the treatment information to certain patient in the treatment system has been realized carrying out comprehensive gathering, very big simplification the operation flow that the electronic medical record was maintained, thereby the effectual maintenance efficiency who improves the electronic medical record, it is convenient also to provide for the user simultaneously.
It should be understood that although the various steps in the flow charts of fig. 1-5 are shown in order as indicated by the arrows, the steps are not necessarily performed in order as indicated by the arrows. The steps are not performed in the exact order shown and described, and may be performed in other orders, unless explicitly stated otherwise. Moreover, at least some of the steps in fig. 1-5 may include multiple steps or multiple stages, which are not necessarily performed at the same time, but may be performed at different times, which are not necessarily performed in sequence, but may be performed in turn or alternately with other steps or at least some of the other steps.
In one embodiment, as shown in fig. 6, there is provided an apparatus for processing an electronic medical record, including: a generating module 602, an obtaining module 604, a searching module 606 and a storing module 608, wherein:
the generating module 602 is configured to obtain the custom configuration information corresponding to the patient identifier, and generate an element column of the electronic medical record summary table corresponding to the patient identifier according to the custom configuration information.
The obtaining module 604 is configured to obtain corresponding historical electronic medical record data according to the patient identifier.
The searching module 606 is configured to search, according to each element in the electronic medical record summary table, record data corresponding to each element from the historical electronic medical record data.
The storage module 608 is configured to store corresponding record data in each element column of the electronic medical record summary table.
In one embodiment, the apparatus further comprises: and a display module.
The display module is used for displaying a plurality of configuration items on the configuration interface. The obtaining module is further used for obtaining a selected configuration item from the plurality of configuration items, and taking the selected configuration item as the user-defined configuration information corresponding to the patient identification. The generating module is further used for generating an element column of the electronic medical record summary table corresponding to the patient identification according to the element name corresponding to the selected configuration item.
In one embodiment, the obtaining module is further configured to obtain a configuration template type, and display a plurality of configuration items corresponding to the configuration template type on the configuration interface.
In one embodiment, the apparatus further comprises: and a matching module.
The acquisition module is also used for acquiring a first element code corresponding to the element from a main table of historical electronic medical record data; and acquiring second element codes corresponding to elements in the electronic medical record summary table. The matching module is used for matching the second element code with the first element code, and when the second element code is the same as the first element code, the element value corresponding to the first element code which is the same as the second element code is obtained. The storage module is further used for storing element values corresponding to the first element codes which are the same as the second element codes to elements corresponding to the second element codes.
In one embodiment, the storage module is further configured to, when there are at least two element values corresponding to a second element code that is the same as the second element code, store the at least two element values under an element corresponding to the second element code according to a chronological order.
In one embodiment, the apparatus further comprises: and determining a module.
The acquisition module is further used for acquiring display attributes of the selected configuration items, wherein the display attributes comprise visible or invisible. The determining module is used for determining an element column of the electronic medical record summary table corresponding to the patient identification according to the display attribute of the configuration item.
In one embodiment, the apparatus further comprises: and an adjusting module.
The acquisition module is also used for acquiring the newly added or deleted configuration items input by the user. The adjusting module is used for dynamically adjusting the element columns in the electronic medical record summary table corresponding to the patient identification according to the element names corresponding to the configuration items.
For specific limitations of the processing apparatus of the electronic medical record, reference may be made to the above limitations on the processing method of the electronic medical record, which are not described herein again. All or part of the modules in the processing device of the electronic medical record can be realized by software, hardware and a combination thereof. The modules can be embedded in a hardware form or independent from a processor in the computer device, and can also be stored in a memory in the computer device in a software form, so that the processor can call and execute operations corresponding to the modules.
In one embodiment, a computer device is provided, which may be a terminal, and its internal structure diagram may be as shown in fig. 7. The computer device includes a processor, a memory, a communication interface, a display screen, and an input device connected by a system bus. Wherein the processor of the computer device is configured to provide computing and control capabilities. The memory of the computer device comprises a nonvolatile storage medium and an internal memory. The non-volatile storage medium stores an operating system and a computer program. The internal memory provides an environment for the operation of an operating system and computer programs in the non-volatile storage medium. The communication interface of the computer device is used for carrying out wired or wireless communication with an external terminal, and the wireless communication can be realized through WIFI, an operator network, NFC (near field communication) or other technologies. The computer program is executed by a processor to implement a method for processing an electronic medical record. The display screen of the computer equipment can be a liquid crystal display screen or an electronic ink display screen, and the input device of the computer equipment can be a touch layer covered on the display screen, a key, a track ball or a touch pad arranged on the shell of the computer equipment, an external keyboard, a touch pad or a mouse and the like.
Those skilled in the art will appreciate that the architecture shown in fig. 7 is merely a block diagram of some of the structures associated with the disclosed aspects and is not intended to limit the computing devices to which the disclosed aspects apply, as particular computing devices may include more or less components than those shown, or may combine certain components, or have a different arrangement of components.
In one embodiment, a computer device is provided, comprising a memory, a processor and a computer program stored on the memory and executable on the processor, the steps of the above-described method embodiments being implemented when the computer program is executed by the processor.
It will be understood by those skilled in the art that all or part of the processes of the methods of the embodiments described above can be implemented by hardware instructions of a computer program, which can be stored in a non-volatile computer-readable storage medium, and when executed, can include the processes of the embodiments of the methods described above. Any reference to memory, storage, database or other medium used in the embodiments provided herein can include at least one of non-volatile and volatile memory. Non-volatile Memory may include Read-Only Memory (ROM), magnetic tape, floppy disk, flash Memory, optical storage, or the like. Volatile Memory can include Random Access Memory (RAM) or external cache Memory. By way of illustration and not limitation, RAM can take many forms, such as Static Random Access Memory (SRAM) or Dynamic Random Access Memory (DRAM), among others.
The technical features of the above embodiments can be arbitrarily combined, and for the sake of brevity, all possible combinations of the technical features in the above embodiments are not described, but should be considered as the scope of the present specification as long as there is no contradiction between the combinations of the technical features.
The above-mentioned embodiments only express several embodiments of the present application, and the description thereof is more specific and detailed, but not construed as limiting the scope of the invention. It should be noted that, for a person skilled in the art, several variations and modifications can be made without departing from the concept of the present application, which falls within the scope of protection of the present application. Therefore, the protection scope of the present patent shall be subject to the appended claims.
Claims (10)
1. A method of processing an electronic medical record, the method comprising:
acquiring custom configuration information corresponding to a patient identifier, and generating an element column of an electronic medical record summary table corresponding to the patient identifier according to the custom configuration information;
acquiring corresponding historical electronic medical record data according to the patient identification;
according to each element in the electronic medical record summary table, searching the record data corresponding to each element from the historical electronic medical record data;
and storing corresponding record data under each element column in the electronic medical record summary table.
2. The method of claim 1, wherein obtaining custom configuration information corresponding to a patient identifier and generating an element column of an electronic medical record summary table corresponding to the patient identifier from the custom configuration information comprises:
displaying a plurality of configuration items on a configuration interface;
acquiring a selected configuration item from the plurality of configuration items, and taking the selected configuration item as user-defined configuration information corresponding to the patient identifier;
and generating an element column of the electronic medical record summary table corresponding to the patient identification according to the element name corresponding to the selected configuration item.
3. The method of claim 2, wherein the presenting a plurality of configuration items at a configuration interface comprises:
the method comprises the steps of obtaining a configuration template type, and displaying a plurality of configuration items corresponding to the configuration template type on a configuration interface.
4. The method according to claim 1, wherein the searching the historical electronic medical record data for the record data corresponding to each element according to each element in the electronic medical record summary table comprises:
acquiring a first element code corresponding to an element from a main table of the historical electronic medical record data;
acquiring second element codes corresponding to elements in the electronic medical record summary table;
matching the second element code with the first element code, and acquiring an element value corresponding to the first element code which is the same as the second element code when the second element code is the same as the first element code;
the storing of the corresponding record data under each element in the electronic medical record summary table comprises:
and storing the element value corresponding to the first element code which is the same as the second element code under the element corresponding to the second element code.
5. The method according to claim 4, wherein storing the element value corresponding to the first element code which is the same as the second element code under the element corresponding to the second element code comprises:
and when at least two element values corresponding to the second element code which is the same as the second element code exist, storing the at least two element values under the element corresponding to the second element code according to the time sequence.
6. The method of claim 4, further comprising:
acquiring the display attribute of the selected configuration item; the display attribute comprises visible or invisible;
and determining an element column of the electronic medical record summary table corresponding to the patient identification according to the display attribute of the configuration item.
7. The method of claim 1, wherein after generating the element column of the electronic medical record summary table corresponding to the patient identifier according to the custom configuration information, the method further comprises:
acquiring newly added or deleted configuration items input by a user;
and dynamically adjusting element columns in the electronic medical record summary table corresponding to the patient identification according to the element names corresponding to the configuration items.
8. An apparatus for processing an electronic medical record, the apparatus comprising:
the generating module is used for acquiring custom configuration information corresponding to the patient identifier and generating an element column of an electronic medical record summary table corresponding to the patient identifier according to the custom configuration information;
the acquisition module is used for acquiring corresponding historical electronic medical record data according to the patient identification;
the searching module is used for searching the record data corresponding to each element from the historical electronic medical record data according to each element in the electronic medical record summary table;
and the storage module is used for storing corresponding record data under each element column in the electronic medical record summary table.
9. A computer device comprising a memory and a processor, the memory storing a computer program, wherein the processor implements the steps of the method of any one of claims 1 to 7 when executing the computer program.
10. A computer-readable storage medium, on which a computer program is stored, which, when being executed by a processor, carries out the steps of the method of any one of claims 1 to 7.
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Application publication date: 20201103 |