CN113963762A - Medical record quality control method, device, equipment and storage medium - Google Patents
Medical record quality control method, device, equipment and storage medium Download PDFInfo
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Abstract
The invention belongs to the technical field of information management and discloses a method, a device, equipment and a storage medium for controlling medical record quality. The method comprises the following steps: determining target quality control point information according to the electronic medical record file; generating a display page according to the electronic medical record file and the target quality control point information; acquiring user input information through the display page; and determining a medical record quality evaluation report according to the user input information. Through the mode, the medical record writing skill is improved. Because the key information influencing the quality of the medical record can be extracted through the quality control point information, namely the quality control point, the user needs to answer the quality control point in the medical record according to the medical record file and the target quality control point information on the display page, the efficiency of enhancing the medical record writing quality of the user is improved, and the user can know the key point where the medical record is written more quickly, so that the method for independently and quickly improving the medical record writing quality of the user is provided.
Description
Technical Field
The invention relates to the technical field of information management, in particular to a method, a device, equipment and a storage medium for controlling medical record quality.
Background
The quality of the medical record is an important index for measuring the medical quality and is an important content of hospital management attention, and because the medical record is the whole record of medical staff on the diagnosis and treatment process of patients, the monitoring of the writing quality of the medical record is an important link for the medical quality management and is the key point for improving the medical quality of hospitals. The medical records of the patient are sorted, bound and filed to form a medical record when the patient is discharged, and the medical record is a source of medical information and is a legal basis for handling medical disputes and disability identification. It can be seen that quality control of medical records is a very important task.
At present, most of hospital medical record quality monitoring is only carried out by a plurality of old doctors, the level of writing medical records by doctors is improved by old doctors and old doctors, but the medical record quality monitoring is not comprehensive in learning according to human experience, and the speed is low, so that the medical record quality monitoring is difficult to adapt to the current requirements on high-quality medical records. Therefore, how to rapidly improve the writing level of medical records of doctors becomes a problem to be solved urgently.
The above is only for the purpose of assisting understanding of the technical aspects of the present invention, and does not represent an admission that the above is prior art.
Disclosure of Invention
The invention mainly aims to provide a method, a device, equipment and a storage medium for controlling the quality of medical records, and aims to solve the technical problem that the medical record writing level of a doctor cannot be quickly improved in the prior art.
In order to achieve the aim, the invention provides a medical record quality control method, which comprises the following steps:
acquiring an electronic medical record file;
determining target quality control point information according to the electronic medical record file;
generating a display page according to the electronic medical record file and the target quality control point information;
acquiring user input information through the display page;
and determining a medical record quality evaluation report according to the user input information.
Optionally, the determining target quality control point information according to the electronic medical record file includes:
determining the medical record type according to the electronic medical record file;
determining the type of the current quality control point according to the type of the medical record;
and acquiring target quality control point information from a preset quality control point database according to the current quality control point type.
Optionally, before obtaining the target quality control point information from the preset quality control point database according to the current quality control point type, the method further includes:
acquiring medical record normative knowledge data;
performing quality control analysis on the medical record normative knowledge data to obtain behavior dimension quality control point data and time dimension quality control point data;
generating quality control point information according to the behavior dimension quality control point data and the time dimension quality control point data;
acquiring medical record type information;
classifying the quality control point information according to the medical record type information to obtain a classification result;
and establishing a preset quality control point database according to the classification result.
Optionally, the generating a display page according to the electronic medical record file and the target quality control point information includes:
generating a medical record actual condition browsing interface according to the electronic medical record;
generating a quality control questionnaire according to the target quality control point information;
and generating a display interface according to the actual situation browsing interface and the quality control questionnaire.
Optionally, the obtaining of the user input information through the display page includes:
monitoring page information of the display page;
determining user personal information, department information and reply information according to the page information;
and determining user input information according to the user personal information, the department information and the reply information.
Optionally, the determining a medical record quality evaluation report according to the user input information includes:
determining the current quality evaluation purpose according to the user input information;
when the current quality evaluation purpose is a training purpose, acquiring corresponding standard medical record quality evaluation information according to the electronic medical record file;
and determining a medical record quality evaluation report according to the standard medical record quality evaluation information and the user input information.
Optionally, after determining the medical record quality evaluation report according to the user input information, the method further includes:
acquiring query information of a user;
selecting corresponding personal information, department information and reply information of the user according to the query information;
generating statistical data according to the user personal information, the department information and the reply information;
and generating a user query result according to the statistical data so as to complete the user query.
In addition, in order to achieve the above object, the present invention further provides a medical record quality control apparatus, including:
the acquisition module is used for acquiring the electronic medical record file;
the processing module is used for determining target quality control point information according to the electronic medical record file;
the control module is also used for generating a display page according to the electronic medical record file and the target quality control point information;
the acquisition module is also used for acquiring user input information;
and the processing module is also used for determining a medical record quality evaluation report according to the user input information.
In addition, in order to achieve the above object, the present invention further provides a medical record quality control apparatus, including: the system comprises a memory, a processor and a medical record quality control program stored on the memory and executable on the processor, wherein the medical record quality control program is configured to implement the steps of the medical record quality control method as described above.
In addition, in order to achieve the above object, the present invention further provides a storage medium, wherein the storage medium stores a medical record quality control program, and the medical record quality control program realizes the steps of the medical record quality control method as described above when being executed by a processor.
The invention obtains an electronic medical record file; determining target quality control point information according to the electronic medical record file; generating a display page according to the electronic medical record file and the target quality control point information; acquiring user input information through the display page; and determining a medical record quality evaluation report according to the user input information. Through the mode, the medical record writing skill is improved. Because the key information influencing the quality of the medical record can be extracted through the quality control point information, namely the quality control point information, a user needs to answer the quality control point in the medical record according to the medical record file and the target quality control point information on the display page, the efficiency of enhancing the medical record writing quality of the user is improved, and the user can know the key point where the medical record is written more quickly, so that the method for independently and quickly improving the medical record writing quality of the user is provided.
Drawings
Fig. 1 is a schematic structural diagram of medical record quality control equipment in a hardware operating environment according to an embodiment of the present invention;
FIG. 2 is a flowchart illustrating a method for quality control of medical records according to a first embodiment of the present invention;
FIG. 3 is a functional diagram of a system according to an embodiment of the method for quality control of medical records of the present invention;
FIG. 4 is a flowchart illustrating a method for quality control of medical records according to a second embodiment of the present invention;
fig. 5 is a block diagram of the medical record quality control apparatus according to the first embodiment of the present invention.
The implementation, functional features and advantages of the objects of the present invention will be further explained with reference to the accompanying drawings.
Detailed Description
It should be understood that the specific embodiments described herein are merely illustrative of the invention and are not intended to limit the invention.
Referring to fig. 1, fig. 1 is a schematic structural diagram of medical record quality control equipment in a hardware operating environment according to an embodiment of the present invention.
As shown in fig. 1, the medical record quality control apparatus may include: a processor 1001, such as a Central Processing Unit (CPU), a communication bus 1002, a user interface 1003, a network interface 1004, and a memory 1005. Wherein a communication bus 1002 is used to enable connective communication between these components. The user interface 1003 may include a Display screen (Display), an input unit such as a Keyboard (Keyboard), and the optional user interface 1003 may also include a standard wired interface, a wireless interface. The network interface 1004 may optionally include a standard wired interface, a Wireless interface (e.g., a Wireless-Fidelity (Wi-Fi) interface). The Memory 1005 may be a Random Access Memory (RAM) Memory, or may be a Non-Volatile Memory (NVM), such as a disk Memory. The memory 1005 may alternatively be a storage device separate from the processor 1001.
Those skilled in the art will appreciate that the configuration shown in fig. 1 does not constitute a limitation of medical record quality control devices and may include more or fewer components than those shown, or some components in combination, or a different arrangement of components.
As shown in fig. 1, a memory 1005, which is a storage medium, may include an operating system, a network communication module, a user interface module, and a medical record quality control program.
In the medical record quality control apparatus shown in fig. 1, the network interface 1004 is mainly used for data communication with a network server; the user interface 1003 is mainly used for data interaction with a user; the processor 1001 and the memory 1005 of the medical record quality control device of the present invention may be arranged in the medical record quality control device, and the medical record quality control device invokes the medical record quality control program stored in the memory 1005 through the processor 1001 and executes the medical record quality control method provided by the embodiment of the present invention.
An embodiment of the present invention provides a medical record quality control method, and referring to fig. 2, fig. 2 is a flowchart illustrating a first embodiment of a medical record quality control method according to the present invention.
In this embodiment, the medical record quality control method includes the following steps:
step S10: and acquiring the electronic medical record file.
It should be noted that, the execution main body of this embodiment is an intelligent terminal, and the intelligent terminal may be a computer, a smart phone, or other intelligent terminals with the same or similar functions to the computer.
It can be understood that, in the embodiment, the method is applied to a training process of medical record quality, in the training process, one evaluated electronic medical record file is selected, corresponding target quality control point information is selected according to the electronic medical record file, and then a display page is generated according to the electronic medical record file and the target quality control point information. The user answers the display page to judge the judgment of the user on the quality of the medical records, and the user can clearly know where each key point is in the medical records writing process through continuous training so as to improve the medical records writing quality of the user. For example: in the training process, a doctor can select an electronic medical record from a medical record library as a training object, and select a plurality of quality control points according to the electronic medical record, wherein the quality control points may include: whether the basic information of the user is completely filled, whether a person in charge signs, whether the birth time of the newborn is filled, whether the rescue time of a doctor and a nurse is reasonable and the like are judged, and whether the answer is compared with a preset correct answer is judged according to the judgment of the key points so as to judge the mastering condition of the doctor on the key points. The target quality control point information is related information of a quality control point corresponding to the case, wherein the related information of the quality control point includes a type and content of the case corresponding to the quality control point, and a diagnosis process (filling a first page of the case, recording admission, recording a first course of disease, recording a course of disease, long-term medical advice, temporary medical advice, recording/advice of discharge, death records, and the like) in which the case is located.
It should be noted that the electronic medical record file is a file in the selected medical record library, and may be acquired through a cloud server of the hospital or through an information transmission connection pipe of the medical record management system, and the embodiment does not limit the way and the manner of acquiring the medical record. The electronic medical record is a real patient medical record, the writing of the medical record generally has a certain writing problem, and a user can find out the problem according to the answer of a quality control point, so that the writing level is convenient to improve. The electronic medical records can be in various forms, and can be scanned paper medical records or medical records in an electronic document mode, which is not limited in this embodiment.
It is understood that the user mentioned in this embodiment generally refers to a doctor or other medical worker related to medical record writing, management and supervision.
Step S20: and determining target quality control point information according to the electronic medical record file.
It should be noted that the quality control point is a quality control point, the target quality control point information is a set of relevant information of the quality control point corresponding to the current electronic medical record file, and the quality control points corresponding to different medical record types are also different, for example: the current electronic medical record file is a newborn medical record, and the quality control point may include parts that other types of medical records do not have, such as "whether the birth time of the newborn is accurately recorded in minutes", "whether the birth weight of the newborn is completely filled" and "whether the general information item of the infant is empty".
In a specific implementation, there are various ways to determine the target quality control point information according to the electronic medical record, and an optimal scheme of this embodiment is as follows: performing keyword identification on the electronic medical record, acquiring keyword entries appearing in the electronic medical record, acquiring corresponding quality control point information from a quality control point database according to the keyword entries, and determining target quality control point information according to the quality control point information. For example: when the terms such as 'newborn' or 'infant patient' are detected, relevant medical record quality control point information of the newborn patient can be called, for example, whether the newborn birth weight record is accurate to gram or not is judged, and for example, the following steps are carried out: when keywords such as "hospitalization" or "ward" are detected, a quality control point related to the hospitalization record can be called, such as "complete filling of the hospitalization record" and the like, and for example: and when the 'death record' is detected, calling a medical record quality control point related to the death record.
Step S30: and generating a display page according to the electronic medical record file and the target quality control point information.
It should be noted that, because the quality evaluation according to the actual medical record can reflect the writing problem that easily occurs under the real condition, the electronic medical record and the target quality control point information are generated into a display page, so that the user can observe the medical record and evaluate according to the quality control point, find the problem in the real medical record, and improve the writing capability of the medical record.
In a specific implementation, the display page is a page interacting with a user, and through target quality control point information on the page, the user can observe writing conditions of medical records in the electronic medical records to answer the writing conditions faithfully, judge whether the writing problems occur in the electronic medical records and the places where the writing problems occur, compare the answers with standard answers to grade the judgment ability of the user, and further evaluate the mastering conditions of the writing quality of the user. The evaluation result may be an examination result or a training result, and the use of the evaluation is not limited.
In this embodiment, the present embodiment proposes a preferable scheme for a page display manner: generating a medical record actual condition browsing interface according to the electronic medical record; generating a quality control questionnaire according to the target quality control point information; and generating a display interface according to the actual situation browsing interface and the quality control questionnaire.
It should be noted that, the electronic file or the scanning piece of the electronic medical record is displayed in the browsing window through the browsing window, the user drags or zooms according to the response requirement of the own quality control point, and the personal sensitive information of the user in the browsing interface can be desensitized and automatically replaced by false information or directly replaced by mosaic.
It can be understood that the quality control questionnaire generated according to the target quality control point information may be selected by the user through a fixed option according to the quality control point information so as to quantify the answer of the user, and if the answer is made by inputting characters by the user, it may be difficult for the machine to objectively evaluate the answer, so that the answer may be made through the fixed option in the form of questionnaire, for example: options "yes", "no", and "not occurred" are set after the problem at the quality control point.
In this embodiment, the generation manner of the quality control questionnaire provides a preferable scheme in this embodiment: classifying the target quality control point information according to a preset medical process classification strategy to obtain classification information; and generating a display interface according to the classification information, the target quality control point information and the actual situation browsing interface.
It should be noted that the preset medical procedure classification strategy is to classify the quality control points according to the procedures of admission, diagnosis, admission and discharge of a normal hospital, for example: the medical records are classified according to 8 large plates of medical record initial page filling, admission record, first medical record, long-term medical advice, temporary medical advice, discharge record/medical advice and death record. Through the mode, the effect of helping a doctor to establish a clinical thinking and medical record writing dimensional logic framework is achieved.
Step S40: and acquiring user input information through the display page.
It should be noted that, by monitoring the control of the display page, the input information of the user can be obtained, and the input information of the user includes the identity information filled by the user and the response information of the user according to the display page.
In this embodiment, page information of the display page is monitored; determining user personal information, department information and reply information according to the page information; and determining user input information according to the user personal information, the department information and the reply information.
It can be understood that the user personal information and department information can be used in the subsequent training statistical process, so that the examination and evaluation of the doctor case history writing level by the hospital or related parts are facilitated, the reply information is the actual answering condition of the user, and the case history writing level of the user is intuitively reflected.
In a specific implementation, the specific manner of obtaining the user input information according to the display page may be: the doctor logs in the system and clicks the "start training" or "start exam" button to start the medical history training/exam. The system randomly reads the electronic medical record electronic file and displays the electronic medical record electronic file on the left side of the window. And the system reads the data items of the quality control points according to the type of the read medical record and displays the data items on the right side of the window. The doctor selects the answers of yes, no and no one by one according to the data items of the quality control points. And when answering, rolling the left window to check the medical record implementation conditions to answer one by one according to the description given by the quality control point. After all the quality control points select the answers and finish clicking and submitting, the system compares the doctor answers with the standard answers and automatically calculates the score of the doctor for the medical record training/examination.
Step S50: and determining a medical record quality evaluation report according to the user input information.
It should be noted that, it is necessary to evaluate the answer of the user so that the physician can know the grasp of the medical record writing method. The specific evaluation method may be: and finding out the answer corresponding to the quality control point according to the medical record number of the electronic medical record. And obtaining an evaluation result by comparing the answer with the reply information input by the user.
In this embodiment, the generation process of the medical record quality evaluation report may be: determining the current quality evaluation purpose according to the user input information; when the current quality evaluation purpose is a training purpose, acquiring corresponding standard medical record quality evaluation information according to the electronic medical record file; and determining a medical record quality evaluation report according to the standard medical record quality evaluation information and the user input information, wherein the medical record quality evaluation report is used for the level of evaluating the writing quality of the medical record by training personnel. For example: as shown in fig. 3, the functional module corresponding to the medical record quality control training may include a medical record quality control training function for training, and then the evaluation result is stored through the medical record quality control training recording function, and the medical record quality control examination function may open a medical record quality control examination according to the requirement to judge the training effect, and the examination form may be consistent with the evaluation form during training.
The embodiment provides a preferred scheme for the acquisition mode of the standard medical record quality evaluation information, wherein the standard medical record quality evaluation information is a standard answer provided by the system: the expert logs in the system to answer, selects the medical record to be evaluated, clicks an expert evaluation button to start expert evaluation, reads an electronic medical record file and displays the electronic medical record file on the left side of a window, the system reads time-behavior quality control point data items according to the type of the read medical record and displays the time-behavior quality control point data items on the right side of the window, the expert selects answers of yes, no and no according to the time-behavior quality control point data items one by one, answers are checked through a window on the left side in the answering process according to the time behavior quality control point description, all quality control points are selected and submitted after clicking, the system automatically calculates the medical record evaluation score and stores the expert answers, and associates the expert answers with the medical record answered by the expert for use in the training purpose. The calculation process of medical record scoring can be a deduction system or an integral system, the proportion of the quality control points of the answer pairs to the total quality control points can be expressed in percentage, and the calculation process of medical record scoring is not limited in the embodiment.
In addition, the embodiment can also be used for performing online inspection on an actual medical record, and when the current quality evaluation purpose is an auditing purpose, the medical record is directly evaluated according to user input information, so that a quality evaluation report of the electronic medical record can be obtained, and the quality evaluation report of the medical record is the evaluation of the writing quality of the medical record.
In this embodiment, after determining the medical record quality evaluation report according to the user input information, the method further includes: acquiring query information of a user; selecting corresponding personal information, department information and reply information of the user according to the query information; generating statistical data according to the user personal information, the department information and the reply information; and generating a user query result according to the statistical data so as to complete the user query.
It should be noted that, a manager can inquire the training condition of each doctor or the quality condition of the medical record according to the requirement, as can be known from the function of quality control statistics of the medical record in fig. 3, the manager can count and manage data such as personal standard reaching condition, department standard reaching condition, personal training accuracy, department training accuracy, personal training statistical chart, department training statistical chart and the like, and the function realizes understanding and analysis of the actual condition of the doctor in the hospital, is beneficial to providing data support for the hospital to manage decision, and improves the hospital management efficiency and the medical record writing quality of the doctor.
In this embodiment, as shown in fig. 3, the following preferable method is proposed for the medical record quality control: the purpose is divided into quality control and training, namely medical record quality control and training functional system, and is divided into 4 functions, medical record quality control training, medical record quality control statistics, medical record quality control maintenance and system management, and the system management is the function in the common information management system, such as: authority management, role management, unit department management, user management and the like. The main functions of quality control and maintenance of medical records are medical record management and examination setting, the medical record management is to add, delete and adjust medical records required to be used, and the examination setting is to set relevant information such as examination time and content.
The embodiment acquires an electronic medical record file; determining target quality control point information according to the electronic medical record file; generating a display page according to the electronic medical record file and the target quality control point information; acquiring user input information through the display page; and determining a medical record quality evaluation report according to the user input information. Through the mode, the medical record writing skill is improved. Because the key information influencing the quality of the medical record can be extracted through the quality control point information, namely the quality control point, the user needs to answer the quality control point in the medical record according to the medical record file and the target quality control point information on the display page, the efficiency of enhancing the medical record writing quality of the user is improved, and the user can know the key point where the medical record is written more quickly, so that the method for independently and quickly improving the medical record writing quality of the user is provided.
Referring to fig. 4, fig. 4 is a flowchart illustrating a medical record quality control method according to a second embodiment of the present invention.
Based on the first embodiment, in step S20, the method for controlling quality of medical records of this embodiment specifically includes:
step S21: and determining the medical record type according to the electronic medical record file.
It should be noted that there are various ways to determine the medical record type according to the electronic medical record, and a preferred scheme in this embodiment is as follows: the first is to associate the medical record number with the medical record type acquired in advance according to the medical record number, and the second is to identify the medical record type according to the keyword identification so as to automatically obtain the medical record type, for example: when the terms of 'newborn' or 'infant patient' and the like are detected, relevant medical record quality control point information of a newborn patient can be called, for example, whether the birth weight record of the newborn is accurate to gram or not can be judged.
Step S22: and determining the type of the current quality control point according to the medical record type.
It can be understood that the quality control points need to be classified according to the medical record types if the quality control points need to correspond to the medical record types, and the quality control points can be classified according to the medical record types, for example: general quality control points applicable to all medical records, quality control points related to newborn admission and the like, different diagnosis processes or quality control point types of different admission states and admission identities. It should be noted that a medical record can correspond to multiple types, and the quality control points corresponding to each type are different, but there is no conflict relationship between them.
Step S23: and acquiring target quality control point information from a preset quality control point database according to the current quality control point type.
It should be noted that each piece of quality control point information is associated with a different quality control point type, corresponding quality control point information can be found from a preset quality control point database through the quality control point type, a set of all quality control points corresponding to the current electronic medical record type is target quality control point information, the preset quality control point data may be a cloud data center stored in a server or a local quality control point data packet, and the embodiment does not limit the expression form of the quality control point database.
In this embodiment, before obtaining the target quality control point information from the preset quality control point database according to the current quality control point type, the method further includes: acquiring medical record normative knowledge data; performing quality control analysis on the medical record normative knowledge data to obtain behavior dimension quality control point data and time dimension quality control point data; generating quality control point information according to the behavior dimension quality control point data and the time dimension quality control point data; acquiring medical record type information; classifying the quality control point information according to the medical record type information to obtain a classification result; and establishing a preset quality control point database according to the classification result.
In a specific implementation, the medical record normative knowledge database is composed of content data in related specified files managed by medical records, such as: the method is characterized in that the knowledge data corresponding to standards and specification documents, such as medical record management regulations of medical institutions and medical record writing basic specifications, are sorted and summarized into a plurality of quality control points according to two dimensions of time and behavior, for example: 300-500 quality control points to simplify the complex problem. This is because, from the perspective of avoiding hospital medical conflict, the problem of medical history generally occurs in both the time dimension and the behavior dimension, for example: the time is not recorded clearly or the behavior specification is problematic, so that the knowledge data can be marked according to certain time keywords and keywords in the aspect of behavior, and then converted into quality control points for evaluating the quality of medical records according to the semantics of the marked positions, wherein the conversion process can be automatic conversion of a machine according to the semantics and manual calibration, and can also be used for setting the quality control points for an administrator by reading the knowledge data at the marked positions.
It should be noted that, in this embodiment, the actual answering situation of the quality control point in the time dimension and the behavior dimension is provided to assist in explaining the scheme, for example: firstly, in the quality control point answering process of action dimension, and in the quality control point answering process of 'medical record homepage filling-patient general information filling complete and no empty item': this item is the "behavior" quality control point, according to a plurality of requirements on general information filling of patients on the first page of medical records, such as "provisional entrance" in the first page of medical records "and" first page of medical records data quality management control index of hospitalization medical records (2016 edition) ", in the state, whether the real medical records used for training are in compliance with" general information of patients is completely filled without null items ", meet the selection" yes ", do not meet the first" no ", and no" do not occur "in the first instance. Secondly, in the answering process of the time dimension quality control point, in the answering process of the quality control point of ' filling in the first page of the medical record-recording the specific time of the patient entering the ward ', the item is the ' time ' quality control point, and the three measurement orders must record the specific time of the patient entering the ward according to the national ' filling quality standard of the first page of the medical record ' (tentative) and the relevant regulation of the ' quality management control index of the first page of the medical record ' (2016 edition) '. Whether the real medical record used for training is matched with 'three survey orders record the specific time of the patient entering the ward', the 'yes' is matched with the selection, the 'no' is not matched with the selection, and the 'no' is selected under the condition. In conclusion, quality control points obtained by inductive analysis of knowledge base data according to the time dimension and the behavior dimension can effectively cover all key problems in the process of writing medical records, and further improve the comprehensiveness and the authenticity of medical record quality evaluation.
The embodiment determines the medical record type according to the electronic medical record file; determining the type of the current quality control point according to the type of the medical record; and acquiring target quality control point information from a preset quality control point database according to the current quality control point type. By the method, the quality control points are acquired, the medical records are evaluated through the medical record types and the corresponding quality control points, quality null points are set more pertinently, specific quality control points can be given according to specific medical record types, and the medical record quality training effect is improved.
In addition, an embodiment of the present invention further provides a storage medium, where a medical record quality control program is stored on the storage medium, and the medical record quality control program, when executed by a processor, implements the steps of the medical record quality control method described above.
Since the storage medium adopts all technical solutions of all the embodiments described above, at least all the beneficial effects brought by the technical solutions of the embodiments described above are achieved, and are not described in detail herein.
Referring to fig. 5, fig. 5 is a block diagram illustrating a medical record quality control apparatus according to a first embodiment of the present invention.
As shown in fig. 5, a medical record quality control apparatus according to an embodiment of the present invention includes:
the acquisition module 10 is used for acquiring an electronic medical record file;
the processing module 20 is used for determining target quality control point information according to the electronic medical record file;
the control module 30 is further configured to generate a display page according to the electronic medical record file and the target quality control point information;
the obtaining module 10 is further configured to obtain user input information;
the processing module 20 is further configured to determine a medical record quality evaluation report according to the user input information.
It should be understood that the above is only an example, and the technical solution of the present invention is not limited in any way, and in a specific application, a person skilled in the art may set the technical solution as needed, and the present invention is not limited thereto.
The embodiment obtains the module 10 and obtains the electronic medical record file; the processing module 20 determines target quality control point information according to the electronic medical record file; the control module 30 generates a display page according to the electronic medical record file and the target quality control point information; the obtaining module 10 obtains the user input information through the display page; the processing module 20 determines a medical record quality evaluation report based on the user input information. Through the mode, the medical record writing skill is improved. Because the key information influencing the quality of the medical record can be extracted through the quality control point information, namely the quality control point information, a user needs to answer the quality control point in the medical record according to the medical record file and the target quality control point information on the display page, the efficiency of enhancing the medical record writing quality of the user is improved, and the user can know the key point where the medical record is written more quickly, so that the method for independently and quickly improving the medical record writing quality of the user is provided.
In an embodiment, the processing module 20 is further configured to determine a medical record type according to the electronic medical record file;
determining the type of the current quality control point according to the type of the medical record;
and acquiring target quality control point information from a preset quality control point database according to the current quality control point type.
In an embodiment, the processing module 20 is further configured to obtain medical record normative knowledge data;
performing quality control analysis on the medical record normative knowledge data to obtain behavior dimension quality control point data and time dimension quality control point data;
generating quality control point information according to the behavior dimension quality control point data and the time dimension quality control point data;
acquiring medical record type information;
classifying the quality control point information according to the medical record type information to obtain a classification result;
and establishing a preset quality control point database according to the classification result.
In an embodiment, the control module 30 is further configured to generate a medical record actual condition browsing interface according to the electronic medical record;
generating a quality control questionnaire according to the target quality control point information;
and generating a display interface according to the actual situation browsing interface and the quality control questionnaire.
In an embodiment, the obtaining module 10 is further configured to monitor page information of the display page;
determining user personal information, department information and reply information according to the page information;
and determining user input information according to the user personal information, the department information and the reply information.
In an embodiment, the processing module 20 is further configured to determine a current quality evaluation purpose according to the user input information;
when the current quality evaluation purpose is a training purpose, acquiring corresponding standard medical record quality evaluation information according to the electronic medical record file;
and determining a medical record quality evaluation report according to the standard medical record quality evaluation information and the user input information.
In an embodiment, the processing module 20 is further configured to obtain query information of a user;
selecting corresponding personal information, department information and reply information of the user according to the query information;
generating statistical data according to the user personal information, the department information and the reply information;
and generating a user query result according to the statistical data so as to complete the user query.
Since the present apparatus employs all technical solutions of all the above embodiments, at least all the beneficial effects brought by the technical solutions of the above embodiments are achieved, and are not described in detail herein.
It should be noted that the above-described work flows are only exemplary, and do not limit the scope of the present invention, and in practical applications, a person skilled in the art may select some or all of them to achieve the purpose of the solution of the embodiment according to actual needs, and the present invention is not limited herein.
In addition, the technical details that are not described in detail in this embodiment can be referred to the medical record quality control method provided in any embodiment of the present invention, and are not described herein again.
Further, it is to be noted that, in this document, the terms "comprises," "comprising," or any other variation thereof, are intended to cover a non-exclusive inclusion, such that a process, method, article, or system that comprises a list of elements does not include only those elements but may include other elements not expressly listed or inherent to such process, method, article, or system. Without further limitation, an element defined by the phrase "comprising an … …" does not exclude the presence of other like elements in a process, method, article, or system that comprises the element.
The above-mentioned serial numbers of the embodiments of the present invention are merely for description and do not represent the merits of the embodiments.
Through the above description of the embodiments, those skilled in the art will clearly understand that the method of the above embodiments can be implemented by software plus a necessary general hardware platform, and certainly can also be implemented by hardware, but in many cases, the former is a better implementation manner. Based on such understanding, the technical solution of the present invention or portions thereof that contribute to the prior art may be embodied in the form of a software product, where the computer software product is stored in a storage medium (e.g. Read Only Memory (ROM)/RAM, magnetic disk, optical disk), and includes several instructions for enabling a terminal device (e.g. a mobile phone, a computer, a server, or a network device) to execute the method according to the embodiments of the present invention.
The above description is only a preferred embodiment of the present invention, and not intended to limit the scope of the present invention, and all modifications of equivalent structures and equivalent processes, which are made by using the contents of the present specification and the accompanying drawings, or directly or indirectly applied to other related technical fields, are included in the scope of the present invention.
Claims (10)
1. A medical record quality control method is characterized by comprising the following steps:
acquiring an electronic medical record file;
determining target quality control point information according to the electronic medical record file;
generating a display page according to the electronic medical record file and the target quality control point information;
acquiring user input information through the display page;
and determining a medical record quality evaluation report according to the user input information.
2. The method of claim 1, wherein determining target quality control point information from the electronic medical record file comprises:
determining the medical record type according to the electronic medical record file;
determining the type of the current quality control point according to the type of the medical record;
and acquiring target quality control point information from a preset quality control point database according to the current quality control point type.
3. The method of claim 2, wherein before obtaining the target quality control point information from the preset quality control point database according to the current quality control point type, the method further comprises:
acquiring medical record normative knowledge data;
performing quality control analysis on the medical record normative knowledge data to obtain behavior dimension quality control point data and time dimension quality control point data;
generating quality control point information according to the behavior dimension quality control point data and the time dimension quality control point data;
acquiring medical record type information;
classifying the quality control point information according to the medical record type information to obtain a classification result;
and establishing a preset quality control point database according to the classification result.
4. The method of claim 1, wherein generating a display page according to the electronic medical record file and the target quality control point information comprises:
generating a medical record actual condition browsing interface according to the electronic medical record;
generating a quality control questionnaire according to the target quality control point information;
and generating a display interface according to the actual situation browsing interface and the quality control questionnaire.
5. The method of claim 1, wherein said obtaining user input information via said display page comprises:
monitoring page information of the display page;
determining user personal information, department information and reply information according to the page information;
and determining user input information according to the user personal information, the department information and the reply information.
6. The method of claim 1, wherein determining a medical record quality assessment report based on the user input information comprises:
determining the current quality evaluation purpose according to the user input information;
when the current quality evaluation purpose is a training purpose, acquiring corresponding standard medical record quality evaluation information according to the electronic medical record file;
and determining a medical record quality evaluation report according to the standard medical record quality evaluation information and the user input information.
7. The method of any of claims 1-6, after determining a medical record quality assessment report based on the user input information, further comprising:
acquiring query information of a user;
selecting corresponding personal information, department information and reply information of the user according to the query information;
generating statistical data according to the user personal information, the department information and the reply information;
and generating a user query result according to the statistical data so as to complete the user query.
8. A medical record quality control device, characterized in that, the medical record quality control device includes:
the acquisition module is used for acquiring the electronic medical record file;
the processing module is used for determining target quality control point information according to the electronic medical record file;
the control module is also used for generating a display page according to the electronic medical record file and the target quality control point information;
the acquisition module is also used for acquiring user input information;
and the processing module is also used for determining a medical record quality evaluation report according to the user input information.
9. A medical record quality control apparatus, characterized in that the apparatus comprises: a memory, a processor, and a medical record quality control program stored on the memory and executable on the processor, the medical record quality control program configured to implement the medical record quality control method of any one of claims 1-7.
10. A storage medium having stored thereon a medical record quality control program which, when executed by a processor, implements the medical record quality control method according to any one of claims 1 to 7.
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| Publication number | Priority date | Publication date | Assignee | Title |
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| CN115881265A (en) * | 2023-02-16 | 2023-03-31 | 中国人民解放军总医院第一医学中心 | Intelligent medical record quality control method, system, equipment and storage medium for electronic medical record |
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| Publication number | Priority date | Publication date | Assignee | Title |
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| CN115881265A (en) * | 2023-02-16 | 2023-03-31 | 中国人民解放军总医院第一医学中心 | Intelligent medical record quality control method, system, equipment and storage medium for electronic medical record |
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