CN112802566A - Method and device for encoding electronic medical record - Google Patents
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- G06F—ELECTRIC DIGITAL DATA PROCESSING
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Abstract
The invention discloses a coding method and a coding device for an electronic medical record, wherein the coding method comprises the following steps: performing semantic recognition on a target case to determine a keyword set corresponding to the target case; performing coding analysis on the keyword set by using a preset analysis model to determine a first coding set corresponding to the keyword set; determining a target code corresponding to the target case from the first coding set; determining a keyword set through semantic analysis, determining codes to be selected by using an analysis model, and screening target codes from the codes to be selected; therefore, an automatic/semi-automatic electronic medical record encoding mode is realized, the labor consumption in the encoding process is saved, and the encoding efficiency is improved; and the target code is determined based on the uniform analysis logic, so that the accuracy of the code is also improved.
Description
Technical Field
The invention relates to the technical field of computers, in particular to a method and a device for encoding an electronic medical record.
Background
In the process of information upgrading in the medical field at present, most medical institutions deploy special information systems, and patient cases are also gradually electronized. And the coding based on the electronic medical record is an indispensable link in the operation and maintenance of the information system. The coding of the electronic medical record is to classify each case according to the international disease classification (ICD for short) and determine the corresponding classification number. It can be said that encoding of a case is a process of further digitizing the case.
In the prior art, encoding of electronic medical records is done manually. Namely, professional encoding personnel can perform ICD inquiry according to various medical information (such as disease diagnosis, pathological diagnosis, operation records and the like) in the electronic medical record, so as to determine the corresponding codes. The manual coding has the defects that a large amount of manpower is consumed, and the efficiency is low; and the error rate is higher due to the experience and subjective judgment of encoding personnel from the encoding result.
Disclosure of Invention
The invention provides a coding method and a coding device for an electronic medical record, which at least solve the technical problems in the prior art.
In a first aspect, the present invention provides a method for encoding an electronic medical record, including:
performing semantic recognition on a target case to determine a keyword set corresponding to the target case;
performing coding analysis on the keyword set by using a preset analysis model to determine a first coding set corresponding to the keyword set;
and determining a target code corresponding to the target case from the first code set.
Preferably, the semantic recognition for the target case to determine the keyword set corresponding to the target case includes:
performing semantic recognition on the target case to determine at least one dominant keyword, and at least one modifier keyword;
and determining the keyword set according to the dominant keyword and the modification keyword.
Preferably, the performing coding analysis on the keyword set by using a preset analysis model to determine a first coding set corresponding to the keyword set includes:
performing code analysis on each leading keyword and each modifying keyword by using a preset analysis model to determine at least one code to be selected;
and determining the first code set according to each code to be selected.
Preferably, the determining, from the first encoding set, a target encoding corresponding to the target case includes:
determining a matching degree index of each code to be selected and the target case;
and determining the code to be selected with the matching degree index meeting the preset condition as the target code.
Preferably, the method further comprises the following steps:
determining a query condition set;
and performing coding analysis on the query condition set by using the analysis model to determine a query code.
Preferably, the query condition set includes a first query condition and a second query condition; the encoding analysis of the query condition set by using the analysis model to determine a query code comprises:
determining a second coding set according to the first query condition;
and determining a query code from the second code set according to the second query condition.
Preferably, the method further comprises the following steps:
and checking the target case to determine abnormal data items in the target case.
In a second aspect, the present invention provides an encoding apparatus for an electronic medical record, including:
the keyword set determining module is used for performing semantic recognition on a target case to determine a keyword set corresponding to the target case;
the code set determining module is used for performing code analysis on the keyword set by using a preset analysis model so as to determine a first code set corresponding to the keyword set;
and the target code determining module is used for determining a target code corresponding to the target case from the first code set.
In a third aspect, the present invention provides a computer-readable storage medium, which stores a computer program for executing the encoding method of the electronic medical record according to the present invention.
In a fourth aspect, the present invention provides an electronic device comprising:
a processor;
a memory for storing the processor-executable instructions;
the processor is used for reading the executable instructions from the memory and executing the instructions to realize the coding method of the electronic medical record.
Compared with the prior art, the coding method and the coding device for the electronic medical record, provided by the invention, have the advantages that a keyword set is determined through semantic analysis, a code to be selected is determined by utilizing an analysis model, and a target code is screened from the code to be selected; therefore, an automatic/semi-automatic electronic medical record encoding mode is realized, the labor consumption in the encoding process is saved, and the encoding efficiency is improved; and the target code is determined based on the uniform analysis logic, so that the accuracy of the code is also improved.
Drawings
Fig. 1 is a schematic flowchart of a method for encoding an electronic medical record according to an embodiment of the present invention;
fig. 2 is a schematic flowchart of another method for encoding an electronic medical record according to an embodiment of the present invention;
fig. 3 is a schematic structural diagram of an encoding apparatus for an electronic medical record according to an embodiment of the present invention.
Detailed Description
In order to make the objects, features and advantages of the present invention more obvious and understandable, the technical solutions in the embodiments of the present invention will be clearly and completely described below with reference to the accompanying drawings in the embodiments of the present invention, and it is apparent that the described embodiments are only a part of the embodiments of the present invention, and not all of the embodiments. All other embodiments, which can be derived by a person skilled in the art from the embodiments given herein without making any creative effort, shall fall within the protection scope of the present invention.
Summary of the application
The coding based on the electronic medical record is an indispensable link in the operation and maintenance of an information system. The coding of the electronic medical record is to classify each case according to the international disease classification (ICD for short) and determine the corresponding classification number. It can be said that encoding of a case is a process of further digitizing the case.
In the prior art, encoding of electronic medical records is done manually. Namely, professional encoding personnel can perform ICD inquiry according to various medical information (such as disease diagnosis, pathological diagnosis, operation records and the like) in the electronic medical record, so as to determine the corresponding codes. The manual coding has the defects that a large amount of manpower is consumed, and the efficiency is low; and the error rate is higher due to the experience and subjective judgment of encoding personnel from the encoding result.
Exemplary method
Therefore, an embodiment of the present invention provides an encoding method for an electronic medical record, so as to at least solve the above technical problems in the prior art. As shown in fig. 1, the method in this embodiment includes the following steps:
The target case is the patient case that needs to be encoded. The target case can include various types of case information such as diagnosis, patient complaint, and treatment process description for the patient. However, since many target cases are doctor's manuals, there may be some cases where the wording and description are not completely standardized and do not correspond exactly to the wording in the coding rules (e.g. "international disease classification"). It is often not possible to directly determine its corresponding target code from semantic analysis of the target case. Therefore, in this embodiment, keywords are extracted from the target case through semantic analysis to form a keyword set.
Specifically, semantic recognition may be performed on the target case to determine at least one dominant keyword, and at least one modifier keyword; and determining a keyword set according to the dominant keywords and the modified keywords. The leading keywords are words describing the contents of diseases, abnormal symptoms, abnormal physical signs, abnormal tissues and the like; such as abdominal pain, fever, etc. The modifying keywords are words for describing the attributes, parts, orientations, disease degrees, property types and other contents of the leading keywords; such as lower limb, right limb, mild, chronic, etc. For example, in the diagnosis "deep vein thrombosis of lower limb", the "thrombosis" is a leading keyword, and the "deep vein of lower limb" is a modifying keyword.
From a complete target case, a plurality of dominant keywords and a plurality of modified keywords can be extracted, and thus a keyword set is determined according to each dominant keyword and each modified keyword.
For example, there are specific target cases in this embodiment, and the contents are as follows: the diagnosis name "residual gastric cancer", patient complaints: after 30 years of gastrotomy, malignant tumor of residual stomach is found for 10 days. The clinic simulates 'residual stomach cancer' to be collected into the department of the inventor. Patients with headache and abdominal pain have the symptoms from the onset of illness.
In the above-mentioned target cases, the diagnosis name "gastric carcinoma residual" is described as "irregular", and therefore, the corresponding code cannot be directly specified in the coding rule. In this step, according to semantic analysis, the dominant keywords can be determined as follows: cancer, malignant tumor, pain; the modification keywords can be determined as follows: stomach, head, abdomen. This may constitute a set of keywords.
And 102, performing coding analysis on the keyword set by using a preset analysis model to determine a first coding set corresponding to the keyword set.
In this embodiment, a preset analysis model may be utilized to perform code analysis on each leading keyword and each modifying keyword to determine at least one candidate code; and determining a first code set according to each code to be selected. The analysis model can be constructed by using a natural language technology based on coding rules and a disease knowledge graph. Specifically, various combination modes between the leading keywords and the modifying keywords can be analyzed by using the analysis model, and if a certain combination mode has a corresponding code in the coding rule, the code is determined as the code to be selected.
For example, in this embodiment, the available combinations and candidate codes are shown in the following table:
| combination mode | Candidate codes |
| Stomach cancer | Code 1 |
| Malignant tumor of residual stomach | Code 2 |
| Headache (headache) | Code 3 |
| Abdominal pain | Code 4 |
In general, there should be a canonical expression corresponding to the target case in the encoding rule in the above combination. That is, one of the candidate codes should be the correct code for the target case.
After the codes to be selected are determined, the codes to be selected are further screened. For example, a matching index of each candidate code to the target case may be determined. Generally, the diagnosis name in the target case is often closer to the canonical representation of the target case in the encoding rule. Therefore, the similarity index between each combination mode and the diagnosis name can be determined based on the calculation modes of semantic similarity, word vector similarity, sentence vector similarity and the like.
For example, in this embodiment, the similarity index of each combination is as follows:
| combination mode | Candidate codes | Index of similarity |
| Stomach cancer | Code 1 | 70％ |
| Malignant tumor of residual stomach | Code 2 | 98％ |
| Headache (headache) | Code 3 | 3％ |
| Abdominal pain | Code 4 | 7％ |
And then, the candidate codes with the matching degree indexes meeting the preset conditions can be determined as target codes. The target code, i.e. the correct code of the target case.
For example, in some cases, the candidate code with the highest similarity index may be determined as the target code. Or the codes to be selected can be sorted according to the similarity index and provided for encoding personnel so as to be convenient for the encoding personnel to select manually and more quickly.
In this embodiment, the code 2 corresponding to the "malignant tumor of residual stomach" is finally determined as the target code.
According to the technical scheme, the beneficial effects of the embodiment are as follows: determining a keyword set through semantic analysis, determining codes to be selected by using an analysis model, and screening target codes from the codes to be selected; therefore, an automatic/semi-automatic electronic medical record encoding mode is realized, the labor consumption in the encoding process is saved, and the encoding efficiency is improved; and the target code is determined based on the uniform analysis logic, so that the accuracy of the code is also improved.
Fig. 1 shows only a basic embodiment of the method of the present invention, and based on this, certain optimization and expansion can be performed, and other preferred embodiments of the method can also be obtained.
Fig. 2 shows another embodiment of the encoding method for electronic medical records according to the present invention. The present embodiment is further developed on the basis of the foregoing embodiments. In the embodiment shown in fig. 1, semantic analysis can be directly performed on the target case to obtain the target code. However, in other situations, there may be some reason why the target case cannot be directly input into the analysis system to start the above method. Therefore, on the basis of the above method, the present embodiment further includes a method of performing query by inputting query conditions to perform encoding. The method specifically comprises the following steps:
In some cases, it may be that the target case cannot be directly used as input. The encoding personnel may determine certain query conditions from the target case as input and perform a query based on the query conditions to determine the correct code.
The specific query condition set comprises a first query condition and a second query condition. The first query condition is similar to the above-mentioned dominant keyword, and may be a word describing the content of diseases, abnormal symptoms, abnormal signs, abnormal tissues, and the like. The second query is similar to the modified keyword, and may be a word describing the attributes, parts, orientations, disease degrees, and property classifications of the dominant keyword.
Specifically, a first query condition may be first input, and a second encoding set may be determined according to the first query condition. For example, the first query condition in this embodiment may be "hypertension". After the query is entered, a plurality of relevant codes may be derived, i.e., a second set of codes is determined.
Then, a second query condition is input on the basis, and a query code is determined from the second code set according to the second query condition. For example, in this embodiment, the second query condition may be "cause: secondary, symptoms: pregnancy, time of disease: puerperium ". Thereby further screening in the second encoding set to obtain the query encoding.
Therefore, the method and the device for determining the codes of the electronic medical records efficiently in a query mode are realized.
In addition, preferably, this embodiment may further include:
Specifically, the target case may be checked if necessary to determine whether there is an error in any of the data items, i.e., to determine an abnormal data item. For example, the operation treatment fee is not zero, but if the operation column is empty, it is obvious that there is an abnormality in the data item. In the embodiment, the abnormal data item can be prompted to a coding person to avoid the occurrence of coding errors caused by the abnormal data item, so that the coding accuracy is further improved.
Exemplary devices
Fig. 3 shows an embodiment of an encoding apparatus for an electronic medical record according to the present invention. The apparatus of this embodiment is a physical apparatus for performing the method described in FIGS. 1-2. The technical solution is essentially the same as that in the above embodiment, and the corresponding description in the above embodiment is also applicable to this embodiment. The device in the embodiment comprises:
the keyword set determining module 301 is configured to perform semantic recognition on the target case to determine a keyword set corresponding to the target case.
The code set determining module 302 is configured to perform code analysis on the keyword set by using a preset analysis model to determine a first code set corresponding to the keyword set.
And an object code determining module 303, configured to determine an object code corresponding to the object case from the first code set.
In addition, on the basis of the embodiment shown in fig. 3, it is preferable that:
the keyword set determination module 301 includes:
a semantic recognition unit 311 for performing semantic recognition on the target case to determine at least one dominant keyword and at least one modifier keyword;
the keyword set determining unit 312 is configured to determine a keyword set according to the dominant keyword and the modified keyword.
The encoding set determination module 302 includes:
a candidate code determining unit 321, configured to perform code analysis on each leading keyword and each modifying keyword by using a preset analysis model to determine at least one candidate code;
a first set determining unit 322, configured to determine a first coding set according to each candidate code.
The target code determination module 303 includes:
a matching degree unit 331, configured to determine a matching degree index between each candidate code and the target case;
and the target code determining unit 332 is configured to determine the candidate code whose matching degree index meets a preset condition as the target code.
Further comprising:
a query module 304 for determining a set of query conditions; and performing coding analysis on the query condition set by using an analysis model to determine a query code.
The query condition set comprises a first query condition and a second query condition; the query module 304 includes:
a first querying unit 341, configured to determine a second encoding set according to the first querying condition;
the second query unit 342 is configured to determine a query encoding from the second encoding set according to the second query condition.
Further comprising:
a checking module 305, configured to check the target case to determine an abnormal data item in the target case.
Exemplary computer program product and computer-readable storage Medium
In addition to the above-described methods and apparatus, embodiments of the invention may also be a computer program product comprising computer program instructions which, when executed by a processor, cause the processor to perform the steps in the methods according to various embodiments of the invention described in the "exemplary methods" section above of this specification.
The computer program product may write program code for carrying out operations for embodiments of the present invention in any combination of one or more programming languages, including an object oriented programming language such as Java, C + + or the like and conventional procedural programming languages, such as the "C" programming language or similar programming languages. The program code may execute entirely on the user's computing device, partly on the user's device, as a stand-alone software package, partly on the user's computing device and partly on a remote computing device, or entirely on the remote computing device or server.
Furthermore, embodiments of the present invention may also be a computer-readable storage medium having stored thereon computer program instructions which, when executed by a processor, cause the processor to perform steps in methods according to various embodiments of the present invention described in the "exemplary methods" section above of this specification.
The computer-readable storage medium may take any combination of one or more readable media. The readable medium may be a readable signal medium or a readable storage medium. A readable storage medium may include, for example, but not limited to, an electronic, magnetic, optical, electromagnetic, infrared, or semiconductor system, apparatus, or device, or a combination of any of the foregoing. More specific examples (a non-exhaustive list) of the readable storage medium include: an electrical connection having one or more wires, a portable disk, a hard disk, a Random Access Memory (RAM), a read-only memory (ROM), an erasable programmable read-only memory (EPROM or flash memory), an optical fiber, a portable compact disc read-only memory (CD-ROM), an optical storage device, a magnetic storage device, or any suitable combination of the foregoing.
The basic principles of the present invention have been described above with reference to specific embodiments, but it should be noted that the advantages, effects, etc. mentioned in the present invention are only examples and are not limiting, and the advantages, effects, etc. must not be considered to be possessed by various embodiments of the present invention. Furthermore, the foregoing disclosure of specific details is for the purpose of illustration and description and is not intended to be limiting, since the invention is not limited to the specific details described above.
The block diagrams of devices, apparatuses, systems involved in the present invention are only given as illustrative examples and are not intended to require or imply that the connections, arrangements, configurations, etc. must be made in the manner shown in the block diagrams. These devices, apparatuses, devices, systems may be connected, arranged, configured in any manner, as will be appreciated by those skilled in the art. Words such as "including," "comprising," "having," and the like are open-ended words that mean "including, but not limited to," and are used interchangeably therewith. The words "or" and "as used herein mean, and are used interchangeably with, the word" and/or, "unless the context clearly dictates otherwise. The word "such as" is used herein to mean, and is used interchangeably with, the phrase "such as but not limited to".
It should also be noted that in the apparatus, devices and methods of the present invention, the components or steps may be broken down and/or re-combined. These decompositions and/or recombinations are to be regarded as equivalents of the present invention.
The previous description of the disclosed aspects is provided to enable any person skilled in the art to make or use the present invention. Various modifications to these aspects will be readily apparent to those skilled in the art, and the generic principles defined herein may be applied to other aspects without departing from the scope of the invention. Thus, the present invention is not intended to be limited to the aspects shown herein but is to be accorded the widest scope consistent with the principles and novel features disclosed herein.
The foregoing description has been presented for purposes of illustration and description. Furthermore, the description is not intended to limit embodiments of the invention to the form disclosed herein. While a number of example aspects and embodiments have been discussed above, those of skill in the art will recognize certain variations, modifications, alterations, additions and sub-combinations thereof.
Claims (10)
1. An encoding method for an electronic medical record is characterized by comprising the following steps:
performing semantic recognition on a target case to determine a keyword set corresponding to the target case;
performing coding analysis on the keyword set by using a preset analysis model to determine a first coding set corresponding to the keyword set;
and determining a target code corresponding to the target case from the first code set.
2. The method of claim 1, wherein the semantically recognizing the target case to determine the set of keywords corresponding to the target case comprises:
performing semantic recognition on the target case to determine at least one dominant keyword, and at least one modifier keyword;
and determining the keyword set according to the dominant keyword and the modification keyword.
3. The method of claim 2, wherein the performing coding analysis on the keyword set by using a preset analysis model to determine a first coding set corresponding to the keyword set comprises:
performing code analysis on each leading keyword and each modifying keyword by using a preset analysis model to determine at least one code to be selected;
and determining the first code set according to each code to be selected.
4. The method of claim 3, wherein the determining, from the first set of codes, a target code corresponding to the target case comprises:
determining a matching degree index of each code to be selected and the target case;
and determining the code to be selected with the matching degree index meeting the preset condition as the target code.
5. The method according to any one of claims 1 to 4, further comprising:
determining a query condition set;
and performing coding analysis on the query condition set by using the analysis model to determine a query code.
6. The method of claim 5, wherein the set of query conditions includes a first query condition and a second query condition; the encoding analysis of the query condition set by using the analysis model to determine a query code comprises:
determining a second coding set according to the first query condition;
and determining a query code from the second code set according to the second query condition.
7. The method according to any one of claims 1 to 4, further comprising:
and checking the target case to determine abnormal data items in the target case.
8. An apparatus for encoding an electronic medical record, comprising:
the keyword set determining module is used for performing semantic recognition on a target case to determine a keyword set corresponding to the target case;
the code set determining module is used for performing code analysis on the keyword set by using a preset analysis model so as to determine a first code set corresponding to the keyword set;
and the target code determining module is used for determining a target code corresponding to the target case from the first code set.
9. A computer-readable storage medium storing a computer program for executing the method for encoding an electronic medical record according to any one of claims 1 to 7.
10. An electronic device, comprising:
a processor;
a memory for storing the processor-executable instructions;
the processor is used for reading the executable instructions from the memory and executing the instructions to realize the coding method of the electronic medical record of any one of the claims 1-7.
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| CN113743414A (en) * | 2021-08-02 | 2021-12-03 | 清华大学 | Method, device and system for identifying focus based on semantic coding |
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