CN111986750A - Electronic medical record template structured detection method - Google Patents
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Abstract
The embodiment of the invention relates to a structured detection method for an electronic medical record template, which comprises the following steps: acquiring electronic medical record template data and an electronic medical record basic data set; carrying out structured data detection marking processing on information element data of electronic medical record template data by using basic data of the electronic medical record basic data set; calculating to obtain the percentage of structured information elements, and extracting an unstructured information element data list; and when the structured information element percentage is not less than the structured percentage threshold, the electronic medical record template structured detection return state is the execution success, and the electronic medical record template structured detection return data is generated by the total structured data, the structured information element percentage and the unstructured information element data list. According to the embodiment of the invention, the electronic medical record template is subjected to structured detection, so that a worker does not need to perform rework due to structured detection after writing the electronic medical record, the work difficulty is reduced, and the work efficiency is improved.
Description
Technical Field
The invention relates to the technical field of data information processing, in particular to a structured detection method for an electronic medical record template.
Background
An Electronic Medical Record System (EMRS) is one of core information systems of Medical institutions, and each Medical institution selects information elements related to a detection diagnosis and treatment process by using the EMRS to establish a corresponding Electronic Medical Record template and completes corresponding Electronic Medical Record compiling based on the Electronic Medical Record template. The information elements of the electronic medical record are shared in various departments in the same medical institution, so that the internal working efficiency can be improved, and the medical experience of a patient can be improved; the medical treatment system realizes sharing among different medical institutions, can reduce the hospitalization cost of patients, and improves the diagnosis and treatment efficiency of the patients. In actual operation, in order to ensure the integrity of the shared information elements, structured detection needs to be performed on the written electronic medical records according to the basic data set of the electronic medical records agreed among departments or institutions.
The current structured detection method is that after the medical institution staff completes the setting of the electronic medical record template and the filling of the electronic medical record, the structured detection is carried out on the electronic medical record according to the basic data set of the electronic medical record, and when the information element loss in the electronic medical record is found, the staff is required to reset the electronic medical record template and fill the information of the electronic medical record again, so that the information input difficulty of the staff is increased, and the work efficiency of the staff is reduced.
Disclosure of Invention
The invention aims to provide an electronic medical record template structured detection method, a computer program product and a computer readable storage medium aiming at the defects of the prior art, and the structured detection is carried out on the electronic medical record template, so that a worker does not need to carry out repeated work due to structured detection after compiling the electronic medical record, the information input difficulty of the worker is reduced, and the work efficiency of the worker is improved; and after the detection is successful, outputting the percentage of the structured information elements which accord with the basic data set of the electronic medical record and the unstructured information element data list which exceeds the basic data set of the electronic medical record, and further refining the structured detection result.
In order to achieve the above object, a first aspect of the embodiments of the present invention provides a method for detecting a template structure of an electronic medical record, where the method includes:
acquiring electronic medical record template data; the electronic medical record template data comprises a plurality of information element data;
acquiring an electronic medical record basic data set corresponding to the electronic medical record template data; the electronic medical record basic data set comprises a plurality of basic data;
carrying out structured data detection marking processing on the information element data by using the basic data to obtain a plurality of marked information element data marked as structured data;
counting the number of the basic data included in the basic data set of the electronic medical record to generate the total number of the basic data; counting the number of the marked information element data included in the electronic medical record template data to generate the total number of the structured data;
generating a percentage of structured information elements according to a ratio of the total number of the structured data to the total number of the basic data;
extracting all information element data which are not marked as the structured data in the electronic medical record template data to form an unstructured information element data list;
when the percentage of the structured information elements is not less than the structured percentage threshold, the electronic medical record template structured detection returns that the state is the execution success; and generating electronic medical record template structured detection return data according to the total structured data, the structured information element percentage and the unstructured information element data list.
Preferably, the performing, by using the basic data, structured data detection and marking processing on the information element data to obtain a plurality of marked information element data marked as structured data specifically includes:
sequentially acquiring the information element data of the electronic medical record template data as current information element data;
and comparing the current information element data by using the basic data of the electronic medical record basic data set in sequence, and when the basic data used for comparison is matched with the current information element data, taking the information element data corresponding to the current information element data as the marked information element data and marking the marked information element data as the structured data.
Preferably, when the structured information element percentage is less than the structured percentage threshold; the electronic medical record template detects the return state as the execution failure in a structuralized way; and generating the electronic medical record template structured detection return data according to the total structured data and the percentage of the structured information elements.
A second aspect of embodiments of the present invention provides a computer program product, which includes computer program code, when executed by a computer, causes the computer to perform the method of the first aspect.
A third aspect of embodiments of the present invention provides a computer-readable storage medium storing computer instructions that, when executed by a computer, cause the computer to perform the method of the first aspect.
According to the electronic medical record template structured detection method, the computer program product and the computer readable storage medium, provided by the embodiment of the invention, structured detection is carried out on the electronic medical record template, so that a worker does not need to repeatedly work due to structured detection after writing the electronic medical record, the information entry difficulty of the worker is reduced, and the work efficiency of the worker is improved; after the detection is successful, the percentage of the structured information elements which accord with the basic data set of the electronic medical record and the data list of the unstructured information elements which exceed the basic data set of the electronic medical record are output, and the structured detection result is further refined.
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Fig. 1 is a schematic view of a structured detection method for an electronic medical record template according to an embodiment of the present invention.
Detailed Description
In order to make the objects, technical solutions and advantages of the present invention clearer, the present invention will be described in further detail with reference to the accompanying drawings, and it is apparent that the described embodiments are only a part of the embodiments of the present invention, 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.
After the staff sets the electronic medical record template through the EMRS (or other medical information systems) or related equipment, the electronic medical record template structured detection method provided by the embodiment of the invention can be used for carrying out structured detection on the electronic medical record template: acquiring the set electronic medical record template data, performing structured data marking on the information element data of the template data by using the basic data of the electronic medical record basic data set corresponding to the electronic medical record template data, counting the percentage of the structured information elements of the template, and finally returning the corresponding electronic medical record template structured detection return state and the electronic medical record template structured detection return data according to the threshold range of the percentage of the structured information elements. Then, the EMRS (or other medical information system) or the related device performs further processing operations (for example, display of prompt information for success/failure of detection, display of structured data information, etc.) according to the electronic medical record template structured detection return status and data.
Or, when a worker wants to perform structured detection on an electronic medical record (an electronic medical record stored locally or a shared electronic medical record acquired from another information system) acquired by an EMRS (or another medical information system) or a related device, the structured detection method provided by the embodiment of the present invention may also be used to perform structured detection: before step 1, acquiring corresponding electronic medical record template data by determining medical record template information of the electronic medical record; and starting from the step 1, carrying out structured data marking on the information element data of the electronic medical record template data by using the basic data of the electronic medical record basic data set corresponding to the electronic medical record template data, counting the percentage of the structured information elements of the structured data, and finally returning the corresponding electronic medical record template structured detection return state and the electronic medical record template structured detection return data according to the threshold range of the percentage of the structured information elements. Then, the EMRS (or other medical information system) or the related device performs further processing operations (for example, display of prompt information for success/failure of detection, display of structured data information, etc.) according to the electronic medical record template structured detection return status and data.
As shown in fig. 1, which is a schematic view of a structured detection method for an electronic medical record template provided by an embodiment of the present invention, the method mainly includes the following steps:
step 1, acquiring electronic medical record template data;
the electronic medical record template data comprises a plurality of information element data.
Specifically, after the electronic medical record template is set by the staff through the EMRS (or other medical information systems) or the related devices, the set electronic medical record template is read from the storage medium of the EMRS (or other medical information systems) or the related devices to obtain electronic medical record template data; for example, the set electronic medical record template is specifically a "transfer record template", and the specific information element data included in the electronic medical record template data obtained in step 1 is shown in table one, where the electronic medical record template data of the "transfer record template" includes 8 information element data: document identification, service object identification, demographic information set (including name, gender, age, etc.), health care institution, health care provider, medical procedure record, allergy medication history, and special area medical history.
More specifically, when a worker wants to perform structured detection on an electronic medical record (an electronic medical record stored locally or a shared electronic medical record acquired from another information system) acquired by an EMRS (or another medical information system) or a related device, the worker first acquires a corresponding electronic medical record template by determining medical record template information of the electronic medical record, and then acquires corresponding electronic medical record template data. For example, the acquired electronic medical record is specifically the "zhang san transfer record" as shown in table two, and since the medical record template information of the "zhang san transfer record" is specifically the "transfer record template", the electronic medical record template data acquired according to the electronic medical record in table two and the specific information element data included therein are also shown in table one.
Watch 1
Watch two
the basic data set of the electronic medical record comprises a plurality of basic data.
Specifically, an electronic medical record basic data set corresponding to the electronic medical record template data is acquired from a storage medium of the EMRS (or other medical information systems) or related equipment.
Here, when the electronic medical record basic data set corresponding to the electronic medical record template data is a set of shared information element data agreed in advance when the electronic medical record information element data is shared among different departments or different medical institutions in the same medical institution, the data set is classified according to the classification of the electronic medical record templates, and each type of electronic medical record template data has a corresponding electronic medical record basic data set.
For example, the basic data set of the electronic medical record corresponding to the "transfer record template" acquired from the EMRS (or other medical information systems) or the storage medium of the related device is specifically the "transfer basic data set", as shown in table three; here, the "transfer basic data set" includes 6 basic data (shared information element data): document identification, service object identification, demographic information set (including name, gender, age, etc.), health service organization, health service person, and medical procedure record.
Watch III
Step 3, carrying out structured data detection marking processing on the information element data by using the basic data to obtain a plurality of marked information element data marked as structured data;
the method specifically comprises the following steps: sequentially acquiring information element data of the electronic medical record template data as current information element data;
and comparing the current information element data by using the basic data of the electronic medical record basic data set in sequence, and when the basic data used for comparison is matched with the current information element data, taking the information element data corresponding to the current information element data as marked information element data and marking the marked information element data as structured data.
The information element data in the electronic medical record template data are subjected to structured detection one by one, the detection method is to sequentially check whether each information element data is included in the electronic medical record basic data set, and if the information element data is included in the electronic medical record basic data set, the information element data is described as structured data and is regarded as marked information element data. The structured data is data conforming to the electronic medical record shared data structure.
For example, if the electronic medical record template data is shown in table one, and the basic data set of the electronic medical record is shown in table three, the structured data in the electronic medical record template data marks the result, as shown in table four; the information element data 1-6 are respectively matched with the basic data 1-6 in the basic data set of the electronic medical record, so that the information element data are marked as structured data; the information element data 7 and 8 do not find matches in the underlying data in the electronic medical record underlying data set, and are therefore not marked as structured data. Resulting in 6 tag information element data (information element data 1 to 6).
Watch four
Here, the total structured data represents the total number of information element data in the acquired electronic medical record template data, which corresponds to the corresponding electronic medical record basic data set.
For example, if the electronic medical record template data is shown in table one, the electronic medical record basic data set is shown in table three, and the structured data flag in the electronic medical record template data is shown in table four, the total number of basic data is 6, and the total number of structured data is 6.
And 5, generating the percentage of the structured information elements according to the ratio of the total number of the structured data to the total number of the basic data.
Specifically, the percentage of structured information elements is (total structured data/total base data) × 100%.
For example, if the electronic medical record template data is shown in table one, the electronic medical record basic data set is shown in table three, the structured data flag in the electronic medical record template data is shown in table four, the total number of basic data is 6, and the total number of structured data is 6, the percentage of structured information elements is (6/6) × 100%: 100%. The electronic medical record template data comprises basic data which is required in all the electronic medical record basic data sets and is used for sharing.
And 6, extracting all information element data which are not marked as structured data in the electronic medical record template data to form an unstructured information element data list.
For example, if the electronic medical record template data is shown in table one, the electronic medical record basic data set is shown in table three, and the structured data markers in the electronic medical record template data are shown in table four, the unstructured information element data list specifically includes two information element data: the history of allergic drugs and the history of epidemic diseases in special areas are shown in table five.
Watch five
And 7, judging whether the structured information element percentage is smaller than a structured percentage threshold, turning to the step 8 when the structured information element percentage is not smaller than the structured percentage threshold, and turning to the step 9 when the structured information element percentage is smaller than the structured percentage threshold.
Here, the structured percentage threshold is a basic threshold used for judging whether structured detection is successful, when the percentage of structured information elements is not less than the structured percentage threshold, it indicates that the electronic medical record template data meets the requirements, and then the electronic medical record compiled based on the electronic medical record template data can be provided to a shared information receiver (EMRS or other information systems or related devices of other departments or different organizations in the same organization) for sharing medical information, and the next step is to go to step 8 to execute a processing flow that the structured detection is successful; on the contrary, when the percentage of the structured information elements is lower than the threshold of the structured percentage, it indicates that the total number of information element data used for sharing the electronic medical record in the electronic medical record template data currently being detected is too low, which may cause that a shared information receiving party (an EMRS or other information systems or related devices of other departments or different organizations in the same organization) cannot extract enough information element data from the electronic medical record compiled based on the electronic medical record template data for diagnosis and treatment, and then the next step should go to step 9 to execute a processing flow that the structured detection fails.
For example, the electronic medical record template data is shown in table one, the electronic medical record basic data set is shown in table three, the percentage of the structured information elements obtained through the steps 1 to 6 is 100%, the structured percentage threshold value is 90%, the percentage of the structured information elements is greater than the structured percentage threshold value, and the process goes to step 8; for another example, the electronic medical record template data is shown in table six, the electronic medical record basic data set is shown in table three, and the percentage of the structured information elements obtained through steps 1 to 6 is: (2/6) ≈ 100% ≈ 33.33%, where the percentage structured threshold is 90%, then the percentage structured information elements is less than the percentage structured threshold and step 9 should be taken.
Watch six
Here, the percentage of structured information elements is greater than or equal to the threshold structured percentage, which indicates that the electronic medical record template data meets the requirements. Setting the electronic medical record template structured detection return state as a successful execution state for carrying out state feedback on EMRS (or other medical information systems) or related equipment for calling the method; the total number of structured data, the percentage of structured information elements and the data list of unstructured information elements are combined into electronic medical record template structured detection return data for carrying out detection refinement data feedback on EMRS (or other medical information systems) or related equipment calling the method.
Step 9, the electronic medical record template is structurally detected to return to the state of execution failure; generating electronic medical record template structured detection return data according to the total structured data and the percentage of structured information elements; go to step 10.
Here, the percentage of structured information elements is less than the structured percentage threshold, indicating that the electronic medical record template data is not satisfactory. Setting the electronic medical record template structured detection return state as execution failure for carrying out state feedback on EMRS (or other medical information systems) or related equipment for calling the method; the total number of the structured data and the percentage of the structured information elements are combined into the structured detection return data of the electronic medical record template for carrying out detection refinement data feedback on EMRS (or other medical information systems) or related equipment for calling the method.
And step 10, performing data return processing on the electronic medical record template structured detection return state and the electronic medical record template structured detection return data.
Here, the method is a processing procedure of performing state feedback on the electronic medical record template structured detection and return state and data to an EMRS (or other medical information system) or related equipment which calls the method.
After receiving a state specifically returned for the structured detection of the electronic medical record template which is successfully executed, the EMRS (or other medical information systems) or related equipment can feed back detection success information to the staff, and further allows the staff to create the corresponding electronic medical record through the template; meanwhile, visual prompt information such as graphs and tables can be further made for workers according to the total number of the structured data and the percentage of the structured information elements, and richer personalized medical information element data can be obtained according to the unstructured information element data list.
After receiving the electronic medical record template structured detection return state which is specifically failed to execute, the EMRS (or other medical information systems) or related equipment can feed back detection failure information to the staff, and further the staff is not allowed to create the corresponding electronic medical record through the template; meanwhile, visual prompting information such as graphs and tables can be further made for workers according to the total number of the structured data and the percentage of the structured information elements.
It should be noted that the embodiment of the present invention also provides a computer-readable storage medium, where instructions are stored, and when the instructions are executed on a computer, the computer is caused to execute the steps and processes of the method provided by the embodiment of the present invention.
Embodiments of the present invention further provide a computer program product, where the computer program product includes a computer program, the computer program is stored in a storage medium, and at least one processor may read the computer program from the storage medium, and execute the steps and processes of the method provided by the embodiments of the present invention.
According to the electronic medical record template structured detection method, the computer program product and the computer readable storage medium, the electronic medical record template is subjected to structured detection, so that a worker does not need to repeatedly work due to structured detection after writing the electronic medical record, the information input difficulty is reduced, and the working efficiency is improved; after the detection is successful, the percentage of the structured information elements which accord with the basic data set of the electronic medical record and the data list of the unstructured information elements which exceed the basic data set of the electronic medical record are output, and the structured detection result is further refined.
Those of skill would further appreciate that the various illustrative components and algorithm steps described in connection with the embodiments disclosed herein may be implemented as electronic hardware, computer software, or combinations of both, and that the various illustrative components and steps have been described above generally in terms of their functionality in order to clearly illustrate this interchangeability of hardware and software. Whether such functionality is implemented as hardware or software depends upon the particular application and design constraints imposed on the implementation. Skilled artisans may implement the described functionality in varying ways for each particular application, but such implementation decisions should not be interpreted as causing a departure from the scope of the present invention.
The steps of a method or algorithm described in connection with the embodiments disclosed herein may be embodied in hardware, a software module executed by a processor, or a combination of the two. A software module may reside in Random Access Memory (RAM), memory, Read Only Memory (ROM), electrically programmable ROM, electrically erasable programmable ROM, registers, hard disk, a removable disk, a CD-ROM, or any other form of storage medium known in the art.
The above-mentioned embodiments are intended to illustrate the objects, technical solutions and advantages of the present invention in further detail, and it should be understood that the above-mentioned embodiments are merely exemplary embodiments of the present invention, and are not intended to limit the scope of the present invention, and any modifications, equivalent substitutions, improvements and the like made within the spirit and principle of the present invention should be included in the scope of the present invention.
Claims (5)
1. A structured detection method for an electronic medical record template is characterized by comprising the following steps:
acquiring electronic medical record template data; the electronic medical record template data comprises a plurality of information element data;
acquiring an electronic medical record basic data set corresponding to the electronic medical record template data; the electronic medical record basic data set comprises a plurality of basic data;
carrying out structured data detection marking processing on the information element data by using the basic data to obtain a plurality of marked information element data marked as structured data;
counting the number of the basic data included in the basic data set of the electronic medical record to generate the total number of the basic data; counting the number of the marked information element data included in the electronic medical record template data to generate the total number of the structured data;
generating a percentage of structured information elements according to a ratio of the total number of the structured data to the total number of the basic data;
extracting all information element data which are not marked as the structured data in the electronic medical record template data to form an unstructured information element data list;
when the percentage of the structured information elements is not less than the structured percentage threshold, the electronic medical record template structured detection returns that the state is the execution success; and generating electronic medical record template structured detection return data according to the total structured data, the structured information element percentage and the unstructured information element data list.
2. The method for detecting the electronic medical record template structure according to claim 1, wherein the detecting and marking of the structured data is performed on the information element data by using the basic data to obtain a plurality of marked information element data marked as structured data, specifically comprising:
sequentially acquiring the information element data of the electronic medical record template data as current information element data;
and comparing the current information element data by using the basic data of the electronic medical record basic data set in sequence, and when the basic data used for comparison is matched with the current information element data, taking the information element data corresponding to the current information element data as the marked information element data and marking the marked information element data as the structured data.
3. The method for detecting the structuring of the electronic medical record template according to claim 1, wherein when the percentage of the structured information elements is smaller than the structured percentage threshold;
the electronic medical record template detects the return state as the execution failure in a structuralized way; and generating the electronic medical record template structured detection return data according to the total structured data and the percentage of the structured information elements.
4. A computer program product, characterized in that the computer program product comprises computer program code which, when executed by a computer, causes the computer to perform the method of any of claims 1-3.
5. A computer-readable storage medium having stored thereon computer instructions which, when executed by a computer, cause the computer to perform the method of any of claims 1-3.
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