CN114155949A

CN114155949A - Examination and verification method, device and equipment for first page of medical record

Info

Publication number: CN114155949A
Application number: CN202110474240.5A
Authority: CN
Inventors: 贾红俊
Original assignee: Shenzhen Kbt Information Technology Co ltd
Current assignee: Shenzhen Kbt Information Technology Co ltd
Priority date: 2021-04-29
Filing date: 2021-04-29
Publication date: 2022-03-08

Abstract

The embodiment of the invention discloses a method, a device and equipment for auditing a first page of a medical record, wherein the method comprises the following steps: identifying a first page of a target medical record to obtain basic information, diagnosis information and operation information of the medical record; acquiring expense detailed information corresponding to a home page of a target medical record, and matching each medical service item and operation information contained in the expense detailed information based on a pre-established mapping relation between operation and a medical service item set to obtain a first auditing result; acquiring a medical data set corresponding to a home page of a target medical record, acquiring a diagnosis matching rule set corresponding to each diagnosis based on a pre-established diagnosis matching rule base, and matching diagnosis information, the medical data set and the diagnosis matching rule set corresponding to each diagnosis to obtain a second examination result. By adopting the mode of the invention, the operation information and the diagnosis information can be audited, and the hospital loss is reduced.

Description

Examination and verification method, device and equipment for first page of medical record

Technical Field

The invention relates to the technical field of medical data, in particular to a method, a device and equipment for auditing a first page of a medical record.

Background

With the innovation of medical insurance, the first page of medical records has raised the important evidence of medical insurance payment from the traditional medical document data. Whether paying based on a DRG (Diagnosis Related Group) or paying based on a DIP (Big Data Diagnosis-Intervention Packet, which is based on the disease species of Big Data, also called a disease species value-dividing method), the integrity and accuracy of each item of Data in the first page of the medical record directly concern whether the medical record can be entered into the Group or not and whether the entered Group is accurate or not, and especially, the Diagnosis information and the operation information are the key auditing Data of the medical record entered Group.

In the prior art, the examination of the first page of the medical record mainly focuses on the examination of the completeness and accuracy of basic information of the medical record, and the examination of the operation information and the diagnosis information is lacked, and once the diagnosis information and the operation information are filled in mistake or are omitted, the hospital can be damaged to different degrees. Therefore, how to provide a scheme for auditing the problems of omission, low editing or high editing of diagnosis of a first page of a medical record and operation, and reducing hospital loss is a problem to be solved by technical personnel in the field.

Disclosure of Invention

The embodiment of the invention aims to provide a method, a device and equipment for auditing a first page of a medical record, which can be used for auditing whether operation information is omitted or low-level and whether diagnosis information is high-level.

In order to solve the above technical problems, embodiments of the present invention provide the following technical solutions:

according to an aspect of the present invention, there is provided a method for auditing a first page of a medical record, the method including:

acquiring a target medical record home page to be audited, and identifying the target medical record home page to obtain basic medical record information, diagnosis information and operation information of the target medical record home page;

acquiring expense detailed information corresponding to a home page of the target medical record, and matching each medical service item contained in the expense detailed information with the operation information based on a mapping relation between operation and a medical service item set established in advance to obtain whether the operation information has a first checking result of omission or low editing;

acquiring a medical data set corresponding to the home page of the target medical record, acquiring a diagnosis matching rule set corresponding to each diagnosis in the diagnosis information based on a pre-established diagnosis matching rule base, and matching the diagnosis information, the medical data set and the diagnosis matching rule set corresponding to each diagnosis to obtain whether the diagnosis information has a second highly-compiled examination result.

Optionally, the step of establishing a mapping relationship between the surgical operation and the medical service item set includes:

respectively counting the association degrees between each operation and each medical service item based on a big data technology, and screening out each medical service item exceeding an operation association degree threshold value to form an associated medical service item set of each operation;

screening out medical service items exceeding a similarity threshold value according to the similarity between the medical service item names and the operation names in the medical service item set related to the operation operations to form a mapping medical service item set of the operation operations;

and establishing a mapping relation between each operation and each mapping medical service item set.

Optionally, the respectively counting association degrees between each surgical operation and each medical service item based on a big data technology, and screening each medical service item exceeding a surgical association degree threshold to form an associated medical service item set of each surgical operation includes:

based on big data technology, respectively screening out medical records containing various surgical operations according to the names of the surgical operations;

acquiring expense detailed information corresponding to each medical record, and calculating the association degree of each medical service item and each operation in the expense detailed information;

and screening out the medical service items with the association degree exceeding the operation association degree threshold value to form an association service item set of the operation.

Optionally, the establishing of the diagnosis matching rule base comprises:

respectively counting keyword combinations associated with disease names of all diseases based on a big data technology; generating a keyword matching rule of each disease according to the keyword combination;

based on big data technology, analyzing the relevance between the basic information of medical records, medicine information, operation information, inspection index information and inspection index information of each disease and each disease; obtaining a combination of basic information characteristics, medicine characteristics, operation characteristics, inspection index characteristics and inspection index characteristics associated with each disease, and generating a characteristic matching rule of each disease according to the combination;

and combining the keyword matching rules and the feature matching rules of the diseases to form a diagnosis matching rule set of the diseases.

Optionally, the matching, based on a mapping relationship between a pre-established surgical operation and a medical service item set, each medical service item included in the expense detailed information with the surgical operation information to obtain whether the surgical operation information has a missing or low-numbered first review result includes:

screening out medical service item sets which do not correspond to the operation information from the expense detailed information based on a mapping relation between operation operations and the medical service item sets established in advance;

if the medical service item set which does not correspond to the operation information is not empty, reversely matching the medical service item which does not correspond to the operation information based on a mapping relation between operation and the medical service item set which is established in advance, confirming missing or low-editing operation, and generating a first auditing result according to the missing or low-editing operation;

and if the medical service item set which does not correspond to the operation information is empty, generating a first review result without omission or low editing of the operation information.

Optionally, the obtaining, based on a pre-established diagnosis matching rule base, a diagnosis matching rule set corresponding to each diagnosis in the diagnosis information, and matching the diagnosis information, the medical data set, and the diagnosis matching rule set corresponding to each diagnosis to obtain whether the diagnosis information has a second highly-compiled review result includes:

acquiring a diagnosis matching rule set corresponding to each diagnosis in the diagnosis information based on a pre-established diagnosis matching rule base;

matching the names of various diagnosed diseases with the keyword matching rules in the corresponding diagnosis matching rule set to obtain a first matching result, and respectively matching the medical data set with the feature matching rules in the diagnosis matching rule base corresponding to various diagnoses to obtain a second matching result;

if the first matching result and the second matching result are both matched successfully, generating a second checking result that the diagnosis information does not have high code; otherwise, acquiring diagnosis of matching failure and the diagnosed matching result information to generate diagnosis information with a high-level second examination result.

Optionally, the method comprises:

analyzing a conjecture diagnosis set corresponding to each operation in the operation information according to the disease category score database and the operation information; and matching the inferred diagnosis set corresponding to each operation in the operation information with the diagnosis information to obtain a third auditing result of whether the diagnosis information is omitted.

Optionally, the analyzing the inferred diagnosis set corresponding to each surgical operation in the surgical operation information according to the disease category score library and the surgical operation information includes:

acquiring a surgical operation from the surgical operation information, and screening a first disease category set corresponding to the surgical operation name of the surgical operation from a disease category score database;

and performing prediction grouping based on the diagnosis information and the operation information of the first page of the target medical record to obtain a disease category score of a predicted disease category, screening a second disease category set which is larger than the disease category score of the predicted disease category in the first disease category set, and obtaining various diagnoses contained in the second disease category set as a conjecture diagnosis set corresponding to the operation.

According to another aspect of the present invention, there is provided an apparatus for auditing a first page of a medical record, the apparatus comprising:

the information acquisition module is used for acquiring a target medical record homepage to be audited, identifying the target medical record homepage and acquiring basic medical record information, diagnosis information and operation information of the target medical record homepage;

the operation auditing module is used for acquiring expense detailed information corresponding to the home page of the target medical record, matching each medical service item contained in the expense detailed information with the operation information based on a mapping relation between operation and a medical service item set established in advance, and acquiring whether the operation information has a first auditing result of omission or underedition;

the diagnosis examination module is used for acquiring a medical data set corresponding to the home page of the target medical record, acquiring a diagnosis matching rule set corresponding to each diagnosis in the diagnosis information based on a pre-established diagnosis matching rule base, and matching the diagnosis information, the medical data set and the diagnosis matching rule set corresponding to each diagnosis to obtain whether the diagnosis information has a second examination result which is highly compiled.

According to another aspect of the present invention, a computer device is provided, which includes a memory, a processor and a computer program stored in the memory and running on the memory, wherein the processor implements the steps of the examination method for the first page of the medical record according to any one of the above items when executing the program.

According to another aspect of the present invention, a computer-readable storage medium is provided, which stores a computer program, which, when executed by a processor, performs the steps of the examination method for a medical record top page of any one of the above.

According to another aspect of the present invention, there is provided a computer program comprising computer readable code which, when run on a computing device, causes the computing device to perform the steps of the method of auditing a medical records front page of any of the above.

The embodiment of the invention has the beneficial effects that: different from the situation of the prior art, in the embodiment of the invention, the basic medical record information, the diagnosis information, the operation information and the cost information of the first page of the target medical record are obtained firstly; then acquiring expense detailed information corresponding to a home page of a target medical record, and matching each medical service item contained in the expense detailed information with the operation information based on a mapping relation between operation and a medical service item set established in advance to obtain whether the operation information has a first checking result of omission or low editing; in addition, a medical data set corresponding to the home page of the target medical record is also obtained, a diagnosis matching rule set corresponding to each diagnosis in the diagnosis information is obtained based on a pre-established diagnosis matching rule base, and the diagnosis information, the medical data set and the diagnosis matching rule set corresponding to each diagnosis are matched to obtain whether the diagnosis information has a second high-level examination result. By adopting the mode of the invention, the examination of whether the operation information is omitted or low-numbered and whether the diagnosis information is high-numbered can be carried out, so that the medical staff of the medical institution can modify the first page of the medical record according to the examination result, and the hospital loss is reduced.

Drawings

One or more embodiments are illustrated by way of example in the accompanying drawings, which correspond to the figures in which like reference numerals refer to similar elements and which are not to scale unless otherwise specified.

Fig. 1 is a flowchart of an optional examination method for a medical record top page according to an embodiment of the present invention;

FIG. 2(a) is a schematic first page of an alternative medical record front page according to an embodiment of the present invention;

FIG. 2(b) is a schematic diagram of a second page of an alternative medical record first page provided in the embodiment of the present invention;

FIG. 3 is a flowchart of an alternative method for auditing surgical procedure information according to an embodiment of the present invention;

FIG. 4 is a flowchart of an alternative method for mapping a surgical procedure to a set of medical services items, according to an embodiment of the present invention;

FIG. 5 is a flowchart of an alternative method for performing a high-level audit on diagnostic information according to an embodiment of the present invention;

FIG. 6 is a flowchart of an alternative method for establishing keyword matching rules according to an embodiment of the present invention;

FIG. 7 is a flowchart of an alternative review method for a first page of a medical record according to an embodiment of the present invention;

FIG. 8 is a flowchart of an alternative method for performing a missed review on diagnostic information according to an embodiment of the present invention;

FIG. 9 is a schematic structural diagram of an alternative apparatus for reviewing the first page of a medical record according to an embodiment of the present invention;

FIG. 10 is a flow chart of an alternative method for managing proper cost during a medical procedure, according to an embodiment of the present invention;

FIG. 11 is a flow chart of an alternative method for effecting proper cost control during a medical procedure, according to an embodiment of the present invention;

fig. 12 is a schematic structural diagram of an alternative electronic device according to an embodiment of the present invention.

Detailed Description

In order to make the objects, technical solutions and advantages of the embodiments of the present invention clearer, the technical solutions in the embodiments of the present invention will be clearly and completely described below with reference to the drawings in the embodiments of the present invention, and it is obvious that the described embodiments are some, but not all, embodiments of the present invention. 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.

In addition, the technical features involved in the embodiments of the present invention described below may be combined with each other as long as they do not conflict with each other.

The embodiments of the present invention provide a method for establishing a mapping relationship between a surgical operation and a medical service item set based on a big data technology, a method for establishing a diagnosis matching rule base based on a big data technology, a method for counting the use of drugs for various diseases based on a big data technology, a method for counting the use of medical consumables for various diseases based on a big data technology, and the like. Before the above method is performed, the method further includes: a data acquisition platform is built based on big data technology, basic medical record information, diagnosis information, operation information, expense detailed information, medicine information, inspection index information, examination index information, discharge summary information, group entering information and the like of each patient are acquired, the information is cleaned according to a preset data dictionary to obtain medical data sets of each medical record, each medical data set is stored by taking the medical record as a unit, and a historical medical database is built.

Fig. 1 is a flowchart of an optional examination method for a medical record top page according to an embodiment of the present invention, where the method includes:

step S101, a target medical record home page to be audited is obtained, the target medical record home page is identified, and basic medical record information, diagnosis information and operation information of the target medical record home page are obtained.

As shown in fig. 2(a) and 2(b), the top page of the target medical record is a brief medical record file for recording basic information, diagnosis information, operation information and cost information of the medical record according to preset specifications; the preset specifications are a unified data record format set by the state or medical record administration of the medical structure. The basic information of the medical record comprises the information of the patient's medical record number, name, sex, age, admission date, admission department, discharge date, discharge department and the like; the diagnostic information includes primary and other diagnoses; the surgical procedure information includes various procedures and operations performed by the patient during the hospitalization period.

Step S102, acquiring expense detailed information corresponding to the home page of the target medical record, and matching each medical service item contained in the expense detailed information with the operation information based on a mapping relation between operation and a medical service item set established in advance to obtain a first checking result of whether the operation information is omitted or low-compiled.

Medical staff may miss filling one or more of the operations in the first page of the medical record due to the high work intensity. And the loss to the hospital from missing a surgical procedure can be enormous. For example, the total cost of hospitalization of a patient: 219491.64 Yuan, the primary diagnosis is: 163.900 cerebral infarction, the former operation is: 38.9301 vein intubation, original group disease species: i: FBS circulatory system diseases: non-conservative, primary disease species score: 938.81 (calculated according to the unit price of 162.38 points, the payment of DIP of medical insurance: 152443.97 Yuan, and the loss of hospital 67047.67 Yuan). Later, through analysis, surgical procedures were missed: 99.9201 needling in traditional Chinese medicine, and after filling in the operation, newly entering the disease species: i63.9.99.9201 cerebral infarction: traditional Chinese medicine acupuncture, new disease category score: 1429.02 (medical insurance DIP payment: 232044.26 Yuan, hospital balance 12552.62 Yuan).

In order to reduce hospital loss, the prior art mainly adopts a manual review mode, but the manual review not only needs high professional degree of review personnel, but also needs how to concentrate attention of the personnel, and the review difficulty is high. The embodiment of the present invention provides a method for determining whether there is a missing surgical operation on a target medical record homepage through a medical service item in the expense detail information to check the surgical operation information, and please refer to the following description in conjunction with fig. 3 for a specific implementation manner.

In practical applications, there may be a case where the surgical operation information itself is empty, or a case where the surgical operation information is empty due to omission. Optionally, before step S102, the method further includes: judging whether the operation information is empty; if not, executing step S102; if yes, acquiring department information corresponding to a home page of the target medical record, and if the department information is a medical department, skipping step S102 and executing step S103; if the department information is surgery, the procedure continues to step S102. This is because the medical patient is relatively rarely subjected to the surgical operation, and if the surgical operation information is empty, the surgical operation information itself can be assumed to be empty. Of course, in the case where the operation information is empty, the step S102 may be directly executed without distinguishing between internal medicine and surgery to ensure that no operation is missed.

Step S103, acquiring a medical data set corresponding to the home page of the target medical record, acquiring a diagnosis matching rule set corresponding to each diagnosis in the diagnosis information based on a pre-established diagnosis matching rule base, and matching the diagnosis information, the medical data set and the diagnosis matching rule set corresponding to each diagnosis to obtain whether the diagnosis information has a second highly-compiled examination result.

In the step, diagnosis information, a medical data set and a diagnosis matching rule set are matched, so that whether the diagnosis is high or not can be judged. For example, the diagnosis on the first page of the target case is named "hyperuricemia", and the medical data set of the case is shown as: when the uric acid level of the patient (male) is 380 mu mol/L, the diagnosis is judged to be high. Because Hyperuricemia (HUA) is, according to medical standards, a level of fasting uric acid higher than 420. mu. mol/L in men and higher than 360. mu. mol/L in women on non-same day under normal purine diet, it is called hyperuricemia.

In an optional scheme, the method of the embodiment of the present invention further includes: and integrating the first and second auditing results and outputting the result.

In an optional scheme, the method of the embodiment of the present invention further includes: and carrying out first data verification on the basic medical record information of the home page of the target medical record, wherein the first data verification is used for judging whether the basic medical record information is normative and complete.

In an optional scheme, the method of the embodiment of the present invention further includes: and performing second data verification on each item of data information in the home page of the target medical record, wherein the second data verification judges whether each item of data information accords with logic or not based on a preset logic judgment rule, for example: whether the age is consistent with the diagnosis, whether the total cost is equal to the cost details, whether the discharge time is longer than the admission time, and the like.

In an optional scheme, the method of the embodiment of the present invention further includes: and judging whether a medical record is not submitted according to the admission information and the discharge information, and if so, sending prompt information to the doctor who does not submit the medical record.

Please refer to the following description in conjunction with fig. 5 for a specific implementation manner of step S103.

Step S102 is described in detail below, and as shown in fig. 3, an optional method for auditing the operation information according to the embodiment of the present invention is a flowchart, where the method includes:

and step S1021, acquiring expense detailed information corresponding to the home page of the target medical record.

As shown in fig. 2(b), the target medical record homepage only records information of total cost and various types of cost, such as examination cost, treatment cost, drug cost, and the like, and does not record specific cost information of each medical service item. Specifically, the expense detailed Information corresponding to the target medical record home page can be obtained from a HIS (Hospital Information System) System through the medical record number of the target medical record home page, the expense detailed Information includes the expenses of each medical service item generated by the patient during hospitalization, and the medical service items can be divided into bed fees, examination fees, nursing fees, operation fees, treatment fees, examination fees, assay fees, medicine fees (western medicine fees, Chinese medicine fees), medical consumable fees and the like according to expense categories.

Step S1022, based on the mapping relationship between the pre-established surgery operation and the medical service item set, the medical service item set not corresponding to the surgery operation information is screened from the expense detailed information.

Currently, surgical operations and medical services are under different systems and frameworks. In the aspect of surgical operation, the country publishes national clinical edition 3.0 surgical operation code (ICD-9-CM3), wherein 13000 surgical operations are contained in the surgical operation code. The name, code, cost category, and charge criteria of a medical service item are generally set by various government departments. For example, Shenzhen city promulgates basic medical service items and prices (2020 edition) of non-profit medical institutions in Shenzhen city, including more than 9000 medical service items.

In order to determine whether the missing operation objects exist in the target medical record home page through the medical service items in the expense detailed information, a mapping relation between the operation operations and the medical service item set is required to be established. Such as: one surgical procedure, named "laparoscopic appendectomy", may correspond to "laparoscopic adduction" + "appendectomy (meaning simplex)"; or with "laparoscopic adduction" + "appendectomy (meaning simplex)" + "appendectomy (suppurative adduction)"; or corresponds to laparoscope plus + appendectomy (which means simple), + "appendectomy (gangrenous plus). Finally, we want to establish the mapping relationship as: the operation ' laparoscopic appendectomy ' corresponds to a medical service project set { ' laparoscopic harvesting ', ' appendectomy (which means simplicity), appendectomy (suppurative harvesting) and appendectomy (gangrenous harvesting) }.

Fig. 4 is a flowchart of an optional method for establishing a mapping relationship between a surgical operation and a medical service item set according to an embodiment of the present invention, where the method includes:

step S401, respectively counting the association degree between each operation and each medical service item based on a big data technology, and screening out each medical service item exceeding an operation association degree threshold value to form an associated medical service item set of each operation.

Specifically, based on big data technology, the medical records containing various surgical operations are screened out according to the names of the surgical operations; acquiring expense detailed information corresponding to each medical record, and calculating the association degree of each medical service item and each operation in the expense detailed information; and screening out the medical service items with the association degree exceeding the operation association degree threshold value to form an association service item set of the operation. For example, one of the surgical operations is selected from among surgical operation codes (ICD-9-CM3) in national clinical edition 3.0, all medical records including the surgical operation are screened from a historical medical database, expense detailed information corresponding to each medical record is obtained, the occurrence rate of each medical service item in the expense detailed information is counted (the occurrence rate is the association degree between the surgical operation and the medical service item), and if the occurrence rate of a certain medical service item exceeds a preset surgical association degree threshold, for example, 95%, the medical service item is screened.

The medical service items can be classified into bed fees, examination fees, nursing fees, operation fees, treatment fees, examination fees, test fees, drug fees (western medicine fees, Chinese patent medicine fees, Chinese herbal medicine fees), medical consumable fees and the like according to the types of the fees. In an optional scheme, the calculating the association degree of each medical service item and each operation in the expense detailed information further comprises screening out each medical service item belonging to the operation type for the expense detailed information of each medical case according to the expense category; and calculating the association degree of each medical service item belonging to the operation type in the expense detail information and each operation. Based on experience, the cost categories for the medical services items for the type of surgical procedure may include treatment costs, surgical costs, and examination costs.

The present inventors have found that, during their research, one surgical operation may correspond to both the medical service item a and the medical service item B. For example, the surgical operation coded as 16.2100x001 "fundus examination" may correspond to four medical service items "fundus examination under slit lamp", "fundus examination under slit lamp (front mirror)", "fundus examination under slit lamp (three-mirror)", and "fundus examination under slit lamp (retinoscope)", in "basic medical service items and prices (2020 edition) of non-profit medical institutions in shenzhen. Thus, under the same big data, the relevance between the operation and the four medical service items is dispersed, and the situation that any medical service item cannot be screened may occur when the screening is performed according to the unified operation relevance threshold. Therefore, a plurality of operation relevance threshold values can be preset, when any medical service item is not screened by adopting the first operation relevance threshold value, a second operation relevance threshold value lower than the first operation relevance threshold value is adopted for secondary screening, and the process is continued until the medical service item is screened out.

Step S402, according to the similarity between the medical service item names and the operation names in the medical service item set related to the operation operations, screening out the medical service items exceeding the similarity threshold value to form a mapping medical service item set of the operation operations.

Specifically, a keyword set of each operation is obtained according to the name of each operation; matching each medical service item name in the associated medical service item set with each keyword in the keyword set to obtain the similarity between each medical service item name in the associated medical service item set and the operation name; and screening out the medical service items exceeding the similarity threshold value to form a mapping medical service item set of each operation.

In an alternative, a plurality of similarity thresholds are preset. Assuming that 70% of the surgical operations and the medical service items are in one-to-one correspondence and the name similarity reaches 90% according to the experience of the experts, the first similarity threshold is set to be 90%, 20% of the surgical operations and the medical service items are in one-to-two correspondence, the name similarity reaches 50%, and the second similarity threshold is set to be 50%. By analogy, a third similarity threshold may be set to 30%.

Taking an operation named as "laparoscopic appendectomy" as an example, the screened related medical service items set includes "laparoscopic harvesting" and "appendectomy (referred to as simplex)". Firstly, extracting a keyword of a name of an operation for laparoscopy and performing appendicectomy, and matching the ' laparoscopy collection ' with the ' laparoscopy and the ' appendicectomy ', wherein the similarity is 50%; similarly, an appendectomy (referred to as a simplex) was matched to a laparoscopic appendectomy with a 50% similarity. At this point, the two medical service items may be screened out according to the second similarity threshold to form a set of mapped medical service items. Of course, if the data in step S401 is sufficient, the relevant medical service item set screened out may further include "appendectomy (suppurative harvest)" and "appendectomy (gangrenous harvest)", at this time, the complete mapping medical service item set of the operation { "laparoscopic harvest", appendectomy (simple), appendectomy (suppurative harvest), appendectomy (gangrenous harvest) } may be obtained.

And step S403, establishing a mapping relation between each operation and each mapping medical service item set.

The following describes in detail how to screen out, from the expense detailed information, a medical service item set that does not correspond to the surgical operation information based on the mapping relationship between the surgical operation and the medical service item set established in fig. 4.

In some embodiments, the cost detail information is first filtered by cost category to screen out medical services items of the type of surgical procedure. Furthermore, all medical service items corresponding to the surgical operations in the surgical operation information are acquired and recorded as a medical service item set A, and all medical service items belonging to the surgical operation type in the expense detailed information are recorded as a medical service item set B. And subtracting the medical service item set A from the medical service item set B to obtain a result, namely the medical service item set which does not correspond to the operation information in the medical service item set B.

Step S1023, determining whether the medical service item set not corresponding to the operation information is empty, if yes, proceeding to step S1025, and if not, proceeding to step S1024.

Step S1024, based on the mapping relation between the pre-established operation and the medical service item set, performing reverse matching on the medical service items which do not correspond to the operation information, confirming the missing or low-numbered operation, and generating a first checking result according to the missing or low-numbered operation.

Specifically, all medical service items which are not corresponding are taken as a whole, reverse matching is performed based on the mapping relation between the operation and the medical service item set, and if one operation is obtained through matching, the operation is determined to be a missing operation. For example, missing operations: 99.9201 needling of Chinese medicine.

If the matching is unsuccessful, splitting each medical service project, and then carrying out reverse matching until the matching is successful. When a medical service item is used for back matching, multiple surgical procedures may be matched. At this point, the physician may be instructed to perform a low-level surgical procedure. At this time, similar operations are searched for by combining various operations included in the first page of the target medical record. For example, the medical service item that does not correspond to the medical service item is "laparoscopic receiving", and reverse matching is performed based on a mapping relationship established in advance, and there may be several hundreds of surgical operation items including "laparoscopic receiving", and if the filled surgical operation includes "appendectomy (which refers to simplex)", a surgical operation similar to "appendectomy (which refers to simplex)" is searched for in the matched surgical operation items, and finally, correct surgical operation information of "appendectomy under laparoscope" is obtained.

Step S1025, generating a first review result without omission or low editing of the operation information.

Fig. 5 is a flowchart of an optional method for performing high-level audit on diagnostic information according to an embodiment of the present invention, where the method includes:

and step S1031, acquiring a medical data set corresponding to the home page of the target medical record.

Step S1032, a diagnosis matching rule set corresponding to each diagnosis in the diagnosis information is obtained based on a diagnosis matching rule base established in advance.

The diagnosis matching rule base comprises mapping of at least one disease and a diagnosis matching rule set, wherein the disease is a disease in international disease classification (such as national clinical edition 2.0 disease diagnosis code (ICD-10)), and the diagnosis matching rule set comprises keyword matching rules and/or feature matching rules. For example, a diagnostic matching rule set that "hyperuricemia" may correspond to is { ("sex ═ male" and "fasting uric acid" >420 μmol/L (twice on different days)) or ("sex ═ female" and "fasting uric acid" >360 μmol/L (twice on different days)) }. In an optional scheme, the establishing of the keyword matching rule includes: respectively counting keyword combinations associated with disease names of all diseases based on a big data technology; and generating a keyword matching rule of each disease according to the keyword combination.

Fig. 6 is a flowchart of an optional method for establishing a keyword matching rule according to an embodiment of the present invention, where the method includes:

step S601, acquiring a disease name of a disease, and performing word segmentation on the disease name to obtain a keyword set of the disease.

In some embodiments, the tokenizing the disease name to obtain the set of keywords for the disease further comprises: and segmenting the disease name, and obtaining a keyword set of the disease according to the approximate words of each segmented word.

Step S602, combining the keywords in the keyword set of the disease according to the word segmentation subjects to obtain a plurality of keyword combinations.

Step S603, based on big data technology, statistics is performed on the association degree between the disease and each keyword combination.

Specifically, screening is performed in the constructed historical medical database according to the disease name, and the medical record hit rate of each keyword combination in the screened historical medical database is counted, wherein the medical record hit rate is the association degree of the disease and each keyword combination.

Step S604, determining whether the number of keyword combinations with the association degree greater than the threshold value of the association degree of the keywords is 0, if so, proceeding to step S608, and if not, proceeding to step S605.

Step S605, determining whether the number of keyword combinations with the association degree greater than the threshold value of the association degree of the keywords is greater than 1, if yes, going to step S606, and if not, going to step S607.

Step S606, each keyword combination with the relevance degree larger than the keyword relevance degree threshold is analyzed to obtain the most relevant keyword combination, and the keyword matching rule of the disease is generated according to the most relevant keyword combination.

Specifically, analyzing each keyword combination with the association degree greater than the keyword association degree threshold includes: and screening the keyword combinations containing the most word-segmentation subjects, counting the occurrence frequency of each keyword combination in each medical record under the screened historical medical database according to the medical record, and screening the keyword combination with the highest average occurrence frequency.

Step S607, generating the keyword matching rule of the disease according to the keyword combination with the association degree larger than the keyword association degree threshold value.

Step S608, reducing the size of the keyword relevancy threshold according to a preset rule, and returning to step S604.

The following exemplifies a keyword matching rule generation process called "acute tonsillitis" as a disease name. Firstly, performing word segmentation and expansion according to disease names to generate a keyword set { "tonsil", "inflammation or red swelling or swelling" }; and secondly, combining according to the word segmentation topics to obtain seven key word combinations of { "tonsil" }, { "inflammation" }, { "red swelling" }, { "tonsil" and "inflammation" }, { "tonsil" and "red swelling" }, { "tonsil" and "swelling" }. And thirdly, calculating the association degree of the seven keyword combinations and the disease based on a big data technology. Assuming that the association degree of { "tonsil" } is 100%, { "inflammation" } is 70%, { "red swelling" } is 80%, { "swelling" } is 95%, { "tonsil" and "inflammation" } is 70%, { "tonsil" and "swelling" } is 95%, { "tonsil" and "red swelling" } is 80%, and the keyword association threshold is 90%, the combination of the two keywords { "tonsil" } and { "tonsil" and "swelling" } is selected. Finally, according to step S607, the keyword combinations with the most word segmentation topics are screened out, and then { "tonsil" and "enlargement" } is screened out as the most relevant keyword combinations.

In an optional aspect, the establishing of the feature matching rule includes: based on big data technology, analyzing the relevance between the basic information of medical records, medicine information, operation information, inspection index information and inspection index information of each disease and each disease; and obtaining the combination of the basic information characteristic, the medicine characteristic, the operation characteristic, the inspection index characteristic and the inspection index characteristic which are associated with each disease, and generating the characteristic matching rule of each disease according to the combination. The combination includes any combination of "or" and "of any of a plurality of basic information features, drug features, surgical features, test index features, and examination index features.

Specifically, in the first step, the relevance between the basic medical record information, the medicine information, the operation information, the inspection index information and the inspection index information of each disease and each disease is respectively calculated based on a big data technology, and a first characteristic relevance threshold is adopted for screening to obtain the basic information characteristics, the medicine characteristics, the operation characteristics, the inspection index characteristics and the inspection index characteristics related to each disease; and secondly, combining the five characteristics according to a preset rule, calculating the association degree of each combined characteristic and each disease, screening by adopting a second characteristic association degree threshold value to obtain the most relevant combination, and generating a characteristic matching rule of each disease according to the combination. The preset rules include preferentially combining features having a high degree of association with a disease, preferentially combining features having complementarity, and the like.

By adopting the method, the mapping relation between each disease and the keyword matching rule and the characteristic matching rule can be established. Further, combining the keyword matching rules and the feature matching rules of the diseases to form a diagnosis matching rule set of the diseases, thereby establishing a diagnosis matching rule base of the diseases. Specifically, the diagnosis matching rule set is as follows: { keyword matching rule, feature matching rule }. It should be noted that, in step S608, the keyword relevancy threshold has a lower limit, and when the keyword relevancy threshold is reduced to the lower limit and no related keyword combination is screened, the process is ended. I.e., the keyword matching feature for the disease is null. Similarly, when a feature matching rule for a disease is established, there may be a case where no matching feature combination occurs, resulting in a null feature matching rule for a disease. Therefore, the diagnosis matching rule set corresponding to each disease may be any one of { keyword matching rule }, { feature matching rule }, { keyword matching rule, feature matching rule }.

Step S1033, the names of the diseases diagnosed in each item are matched with the keywords in the corresponding diagnosis matching rule set to obtain a first matching result, and the medical data set is respectively matched with the feature matching rules in the diagnosis matching rule base corresponding to each diagnosis to obtain a second matching result.

In step S1034, if the first matching result and the second matching result are both successfully matched, step S1036 is performed, otherwise, step S1035 is performed.

The following description will be made by taking "hyperuricemia" as an example. Assuming that the diagnosis in the target case information is "hyperuricemia", the feature matching rule corresponding to "hyperuricemia" is ("sex is male" and "fasting uric acid" >420 μmol/L (twice on different days)) or ("sex is female" and "fasting uric acid" >360 μmol/L (twice on different days)). Respectively acquiring gender information and index values of fasting blood uric acid in a medical data set corresponding to a home page of a target medical record, and if the acquired gender is male, the value of fasting blood uric acid is 400 mu mol/L in 1 day/3 month and 370 mu mol/L in 2 days/3 month, indicating that the matching is unsuccessful by the system and entering step S504; assuming that the obtained gender is female, the fasting blood uric acid value in 1 day 3 is 400 mu mol/L, and the fasting blood uric acid value in 2 days 3 is 370 mu mol/L, the system indicates that the matching is successful.

Step S1035, obtaining diagnosis of failed matching and matching result information of the diagnosis to generate diagnosis information with a high-level second review result.

The matching result information comprises diagnosis matching rules with failed matching, and features and feature values with failed matching in the diagnosis matching rules. Continuing the above case, the following information is obtained in the medical data set corresponding to the first page of the target medical record: the sex is "male", the value of "fasting blood uric acid" at 3-month-1-day is 400 μmol/L, the value of "fasting blood uric acid" at 3-month-2-day is 370 μmol/L, after matching is performed by adopting the step S503, the diagnostic matching rule for confirming the matching failure is { "sex is male" and "fasting blood uric acid" >420 μmol/L (twice on different days) }, the characteristic of the matching failure is "fasting blood uric acid" at 3-month-1-day, and the characteristic value is 400 μmol/L; the second characteristic of the matching failure is 3 months and 2 days 'fasting blood uric acid', and the characteristic value is 370 mu mol/L. And generating a second examination result according to the information. Such as: the second result is: the medical record does not meet the diagnosis of hyperuricemia. The specific situation is as follows: the patient has fasting blood uric acid at 3 months and 1 day, the characteristic value is 400 mu mol/L, and the fasting blood uric acid at 3 months and 2 days has a characteristic value of 370 mu mol/L; a diagnostic matching rule set that does not meet "fasting uric acid" { "gender ═ male" and "fasting uric acid" >420 μmol/L (twice on non-same day) }.

Step S1036, generating a second review result that the diagnosis information does not have high code.

As shown in fig. 7, a flowchart of another optional examination method for a first page of a medical record provided in an embodiment of the present invention is shown, where the method includes the steps of:

step S701, acquiring a target medical record homepage to be audited, and identifying the target medical record homepage to obtain basic medical record information, diagnosis information and operation information of the target medical record homepage.

Step S702, acquiring expense detailed information corresponding to the home page of the target medical record, and matching each medical service item contained in the expense detailed information with the operation information based on a mapping relation between the operation and a medical service item set established in advance to obtain a first checking result of whether the operation information is omitted or low-compiled.

Step S703 is to obtain a medical data set corresponding to the home page of the target medical record, obtain a diagnosis matching rule set corresponding to each diagnosis in the diagnosis information based on a pre-established diagnosis matching rule base, and match the diagnosis information, the medical data set, and the diagnosis matching rule set corresponding to each diagnosis to obtain whether the diagnosis information has a second highly-compiled audit result.

Step S704, analyzing a presumption diagnosis set corresponding to each operation in the operation information according to the disease category score library and the operation information, and matching the presumption diagnosis set corresponding to each operation in the operation information with the diagnosis information to obtain a third audit result of whether the diagnosis information is omitted.

Steps S701 to S703 are the same as steps S101 to S103 in the embodiment of fig. 1, and are not repeated herein.

In an optional embodiment, before step S704, the method further includes: and correcting the operation information based on the first examination result.

As shown in fig. 8, an optional method for performing a missed review on diagnostic information according to an embodiment of the present invention is a flowchart, where the method includes:

step S801, acquiring a surgical operation from the surgical operation information, and screening a first disease category set corresponding to the surgical operation name of the surgical operation from a disease category score database.

The disease category score database is a disease category score database based on DIP payment published by the state or the authority. Each disease category corresponds to a disease category combination code, a disease category combination name and a disease category score. The disease category combination name is composed of a diagnosis name, a surgical operation name 1, a surgical operation name 2 … and a surgical operation name n. Therefore, all the disease types containing the operation names can be found by searching the operation names in the disease type score database.

Step S802, performing prediction grouping based on the diagnosis information and the operation information of the first page of the target medical record to obtain the disease category score of the predicted disease category, screening a second disease category set larger than the disease category score of the predicted disease category in the first disease category set, and acquiring various diagnoses contained in the second disease category set as a conjecture diagnosis set corresponding to the operation.

The disease category grouping based on the DIP payment mainly judges main diagnosis and all operation information, so that the predicted grouping can be carried out according to the diagnosis information and the operation information of the first page of the target medical record, and the disease category score of the predicted grouping is obtained. The present invention aims to reduce hospital losses and therefore does not take into account diagnoses with a lower lesion score than the predicted lesion.

Step S803, using the above method, obtains a set of inferred diagnoses corresponding to each operation in the surgical operation information.

Step S804, matching the presumption diagnosis set corresponding to each surgical operation in the surgical operation information with the diagnosis information, if the presumption diagnosis set includes one of the diagnoses in the diagnosis information, the matching is successful, otherwise, the matching is failed.

Step S805 is to determine whether the inferred diagnosis sets corresponding to all the surgical operations in the surgical operation information are successfully matched with the diagnosis information, if yes, the process proceeds to step S807, and if not, the process proceeds to step S806.

Step S806, obtaining the operation unsuccessfully matched with the diagnosis information, and generating a third auditing result with missing diagnosis information according to the conjecture diagnosis set corresponding to the operation.

And if a plurality of operation operations which are not successfully matched exist, respectively obtaining a speculative diagnosis set corresponding to each operation to generate a third auditing result with missing diagnosis information.

In step S807, a third audit result with no missing diagnostic information is generated.

In some embodiments, in step S804 or step S806, the method further includes: and judging the diagnosis number in the presumption diagnosis set corresponding to each operation, and if the diagnosis number in the presumption diagnosis set is larger than a screening threshold, further screening the presumption diagnosis set based on historical group entry information related to a home page of a target medical record, wherein the historical group entry information is historical group entry disease type information of each medical record inquired in a historical medical database according to patient information or medical structure information corresponding to the home page of the target medical record.

Further screening each set of putative diagnoses based on historical cohort information associated with the top page of the target medical records specifically includes: and acquiring various items of diagnosis information in the historical grouping information, judging whether various items of diagnosis in the inferred diagnosis set are contained in various items of diagnosis information in the historical grouping information, and deleting the diagnosis if the various items of diagnosis in the inferred diagnosis set are not contained in the various items of diagnosis information in the historical grouping information. In both the patient and the medical structure, the historical grouping information is generally concentrated on some disease types, and each disease type corresponds to one diagnosis, so that the inferred diagnosis set can be further screened according to various diagnosis information in the historical grouping information, and in step S806, a third audit result with missing diagnosis information is generated according to the screened inferred diagnosis set. Such as: there are omissions in the diagnosis corresponding to the surgical procedure "appendectomy", and the possible corresponding diagnoses include: ileocecal abscess and acute suppurative appendicitis.

According to the examination method of the first page of the medical record, provided by the embodiment of the invention, basic medical record information, diagnosis information, operation information and cost information of the first page of the target medical record are obtained; then acquiring expense detailed information corresponding to a home page of a target medical record, and matching each medical service item contained in the expense detailed information with the operation information based on a mapping relation between operation and a medical service item set established in advance to obtain whether the operation information has a first checking result of omission or low editing; in addition, a medical data set corresponding to the home page of the target medical record is also obtained, a diagnosis matching rule set corresponding to each diagnosis in the diagnosis information is obtained based on a pre-established diagnosis matching rule base, and the diagnosis information, the medical data set and the diagnosis matching rule set corresponding to each diagnosis are matched to obtain whether the diagnosis information has a second high-level examination result. By adopting the mode of the invention, the examination of the problems of omission, low editing, high editing and the like of the operation information and the diagnosis information in the first page of the medical record can be carried out, so that the medical staff of the medical institution can modify the first page of the medical record according to the examination result, and the hospital loss is reduced.

According to an embodiment of the present invention, there is provided an apparatus for examining and verifying a first page of a medical record, as shown in fig. 9, which is a schematic structural diagram of an apparatus for examining and verifying a first page of a medical record provided in an embodiment of the present invention, where the apparatus 900 for examining and verifying a first page of a medical record includes:

an information obtaining module 902, configured to obtain a target medical record homepage to be reviewed, and identify the target medical record homepage to obtain basic medical record information, diagnostic information, and operation information of the target medical record homepage;

the operation auditing module 904 is used for acquiring expense detailed information corresponding to the home page of the target medical record, matching each medical service item contained in the expense detailed information with the operation information based on a mapping relation between operation and a medical service item set established in advance, and acquiring whether the operation information has a first auditing result of omission or underedition;

the diagnosis examination module 906 obtains a medical data set corresponding to the home page of the target medical record, obtains a diagnosis matching rule set corresponding to each diagnosis in the diagnosis information based on a pre-established diagnosis matching rule base, and matches the diagnosis information, the medical data set and the diagnosis matching rule set corresponding to each diagnosis to obtain whether the diagnosis information has a second highly-compiled examination result.

The device can execute the examination method of the first page of the medical record in the embodiment of the method, has corresponding functional modules and beneficial effects of the method, and can refer to the examination method of the first page of the medical record provided by the embodiment of the method without detailed technical details in the embodiment.

According to an embodiment of the present invention, there is provided a method for reasonably controlling fees in a medical procedure, as shown in fig. 10, which is a flow chart of an alternative method for reasonably controlling fees in a medical procedure, according to an embodiment of the present invention, the method includes the steps of:

step S1001 counts the use of the medicines for each disease type based on the big data technique, obtains the use frequency of each medicine for each disease type, and adds the medicine whose use frequency exceeds the medication frequency threshold to the necessary medicine list for each disease type.

First, a historical medical database is built by collecting medical data sets of medical records of which a plurality of medical institutions have completed a DIP enrollment or a DRG enrollment, the medical institutions preferably local benchmarking medical institutions. Because the medication situations of the medical institutions are inconsistent, when a historical medical database is established, the data of the medicines in the charging items of the medical institutions are required to be standardized based on the medicine catalog standards published by various official authorities, and a uniform medicine index is established. Another alternative is: only the frequency of use of the medical insurance medicine is counted.

Specifically, the method includes the steps of counting various diseases contained in a historical medical database, obtaining one of the diseases, screening the historical medical database, obtaining expense detailed information of each medical record in the screened historical medical database, counting various medicines and the medication frequency of each medicine contained in the expense detailed information of each medical record, and adding a certain medicine to a necessary medicine catalog of the disease if the medication frequency of the medicine exceeds a medication frequency threshold. For example, if a drug is used in 95% of cases, assuming that the medication frequency threshold is 90%, the drug is added to the list of necessary drugs for the type of the case.

And step S1002, performing prediction grouping according to the diagnosis information and the operation information of the current medical record to obtain a predicted disease type.

In some optional embodiments, performing the predictive grouping according to the diagnosis information and the surgical operation information of the current medical record, and obtaining the predicted disease category further includes: and checking the diagnosis information and/or the operation information of the current medical record, and performing prediction grouping after the diagnosis information and/or the operation information is pre-modified according to the checking result to obtain a predicted disease type.

In some optional embodiments, the auditing the surgical procedure information of the current medical record includes:

acquiring expense detailed information corresponding to a current medical record, and matching each medical service item contained in the expense detailed information with the operation information based on a pre-established mapping relation between operation and a medical service item set to obtain whether the operation information has a first checking result of omission or low editing;

the established mapping relation between the surgical operation and the medical service item set comprises:

In some optional embodiments, the reviewing the diagnostic information of the current medical record includes:

acquiring a medical data set corresponding to a current medical record, acquiring a diagnosis matching rule set corresponding to each diagnosis in the diagnosis information based on a pre-established diagnosis matching rule base, and matching the diagnosis information, the medical data set and the diagnosis matching rule set corresponding to each diagnosis to obtain whether the diagnosis information has a high-level second examination result;

the establishing of the diagnosis matching rule base comprises the following steps:

In some optional embodiments, the reviewing the diagnosis information of the current medical record further comprises: analyzing a conjecture diagnosis set corresponding to each operation in the operation information according to the disease category score database and the operation information; and matching the inferred diagnosis set corresponding to each operation in the operation information with the diagnosis information to obtain a third auditing result of whether the diagnosis information is omitted.

For technical details that are not described in detail in this embodiment, reference may be made to a method for auditing diagnosis information and/or surgical operation information in an auditing method of a first page of a medical record provided in an embodiment of the method of the present invention.

Step S1003, acquiring a medication order of a doctor, judging whether each target medicine in the medication order is contained in a necessary medicine catalogue corresponding to the predicted disease type, and if not, acquiring the medication frequency of the target medicine to generate first prompt information.

According to the embodiment of the invention, the DDDs (Defined Daily Dose frequency) of a certain medicine under each disease is obtained by counting the big medication data of each benchmarking medical institution, and the DDDs is used for reminding a doctor to take the medicine. Smaller DDDs represent less and less use of the drug, and a single doctor is reminded of whether the drug should be used or not when using the drug.

In an optional aspect, the method further comprises: counting the drug proportion of each disease based on a big data technology to obtain the standard drug proportion of each disease; and judging whether the ratio of the total cost of each target medicine to the total cost of each medical service item in the medication order exceeds the standard medicine ratio corresponding to the predicted disease category, if so, generating third prompt information.

As shown in fig. 11, another alternative flowchart of a method for controlling a fee in a medical procedure is provided, where the method includes the steps of:

in step S1101, the use of the medicines for each disease is counted based on the big data technique to obtain the use frequency of each medicine for each disease, and the medicine whose use frequency exceeds the medication frequency threshold is added to the necessary medicine list for each disease.

Step S1102, the using conditions of the medical consumables of various diseases are counted respectively based on a big data technology, and reasonable price intervals for the medical consumables of various diseases are obtained.

Similarly, since the medical consumables of each medical institution are not consistent in use, when the historical medical database is established, the data of each medical consumable in the charging items of each medical institution needs to be standardized based on the medical consumable use standards published by each local authority, so as to establish a uniform medical consumable index.

The medical consumables comprise chargeable medical consumables and non-chargeable medical consumables, the embodiment of the invention only counts the chargeable medical consumables, and in practical application, the embodiment of the invention also counts the high-value medical consumables, such as: orthopedic implant consumables, blood vessel interventional instruments and neurosurgery high-value consumables. These high-value medical consumables generally appear in some disease categories in a concentrated manner, so the disease categories needing statistics can be screened out before the use condition of the medical consumables is counted.

Specifically, a disease category is obtained from the screened disease categories, a historical medical database is screened based on the disease category, expense detailed information of each medical case is obtained from the screened historical medical database, and the service conditions of various medical consumables in the expense detailed information of each medical case are counted, so that a reasonable price interval for using various medical consumables is obtained. For example: through statistics, the reasonable price interval of the domestic inguinal hernia patch is 2500 yuan to 2600 yuan under the operation-II disease category.

Step S1103, obtaining the predicted disease type according to the diagnosis information and the operation information of the current medical record.

Step S1104 is to obtain medication instructions of the doctor, determine whether each target drug in the medication instructions is included in the necessary drug list corresponding to the predicted disease category, and if not, obtain the medication frequency of the target drug to generate first prompt information.

Step S1105, judging whether the medical consumable expense in the medication order is in the reasonable price interval of the medical consumable under the predicted disease category, if not, generating a third prompt message.

For example, if an imported inguinal hernia patch is provided in a medication order provided by a doctor and the price of the imported inguinal hernia patch is 6000 yuan, the system generates prompt information to prompt the doctor to provide medical consumables in a reasonable price interval.

Step S1101, step S1103 and step S1104 are the same as step S1001, step S1002 and step S1003 respectively in the embodiment of fig. 10, and are not described again here.

According to an embodiment of the present invention, an electronic device is provided, as shown in fig. 12, which is a schematic structural diagram of an optional electronic device provided in the embodiment of the present invention, and the electronic device may include a processor 1201, a communication interface 1202, a memory 1203, and a communication bus 1204, where the processor 1201, the communication interface 1202, and the memory 1203 complete communication with each other through the communication bus 1204. The processor 1201 may invoke logic instructions in the memory 1203 to perform a method according to any of the above embodiments, for example, a method for auditing a first page of a medical record, the method including: acquiring a target medical record home page to be audited, and identifying the target medical record home page to obtain basic medical record information, diagnosis information and operation information of the target medical record home page; acquiring expense detailed information corresponding to a home page of the target medical record, and matching each medical service item contained in the expense detailed information with the operation information based on a mapping relation between operation and a medical service item set established in advance to obtain a first checking result of whether the operation information is omitted or low-compiled; and acquiring a medical data set corresponding to the home page of the target medical record, and matching the diagnosis information with the medical data set based on a pre-established diagnosis matching rule base to obtain whether the diagnosis information has a second highly-compiled examination result.

Further, the logic instructions in the memory 1203 may be implemented in the form of software functional units and stored in several computer readable storage media when sold or used as a stand-alone product. Based on such understanding, the technical solution of the present invention may be embodied in the form of a software product, which is stored in a storage medium and includes instructions for causing a computer device (which may be a personal computer, a server, or a network device) to execute all or part of the steps of the method according to the embodiment of the present invention. And the aforementioned storage medium includes: a U-disk, a removable hard disk, a Read-Only Memory (ROM), a Random Access Memory (RAM), a magnetic disk or an optical disk, and other various media capable of storing program codes.

According to an embodiment of the present invention, a computer-readable storage medium is provided, which is of a type described in the electronic device embodiment, and stores computer-executable instructions, and when the computer-executable instructions are executed by a processor, the processor executes the method described in any one of the above embodiments of the present invention, for example, the steps of the method for auditing the first page of a medical record.

Through the above description of the embodiments, those skilled in the art will clearly understand that each embodiment can be implemented by software plus a general hardware platform, and certainly can also be implemented by hardware. Based on such understanding, the technical solutions mentioned above may be embodied in the form of a software product, which may be stored in a computer-readable storage medium, such as ROM/RAM, magnetic disk, optical disk, etc., and includes instructions for causing a computer device (which may be a personal computer, a server, or a network device) to execute the method according to each embodiment or some parts of the embodiments.

Finally, it should be noted that: the above examples are only intended to illustrate the technical solution of the present invention, but not to limit it; within the idea of the invention, also technical features in the above embodiments or in different embodiments may be combined, steps may be implemented in any order, and there are many other variations of the different aspects of the invention as described above, which are not provided in detail for the sake of brevity; although the present invention has been described in detail with reference to the foregoing embodiments, it will be understood by those of ordinary skill in the art that: the technical solutions described in the foregoing embodiments may still be modified, or some technical features may be equivalently replaced; and the modifications or the substitutions do not make the essence of the corresponding technical solutions depart from the scope of the technical solutions of the embodiments of the present application.

Claims

1. A method for auditing a first page of a medical record is characterized by comprising the following steps:

2. The method of claim 1, further comprising: establishing a mapping relation between the operation and a medical service project set:

3. The method of claim 2, wherein the step of counting the association degree between each surgical operation and each medical service item based on big data technology, and the step of filtering out each medical service item exceeding the threshold value of the association degree to form the set of associated medical service items for each surgical operation comprises:

4. The method of claim 1, further comprising:

establishing a diagnosis matching rule base:

5. The method according to claim 4, wherein the matching, based on the pre-established mapping relationship between the surgical operation and the set of medical service items, each medical service item included in the expense detailed information with the surgical operation information to obtain whether there is a missing or low-numbered first review result of the surgical operation information comprises:

6. The method according to claim 1, wherein the obtaining a diagnosis matching rule set corresponding to each diagnosis in the diagnosis information based on a pre-established diagnosis matching rule base, and matching the diagnosis information, the medical data set and the diagnosis matching rule set corresponding to each diagnosis to obtain whether the diagnosis information has a second highly-compiled review result comprises:

7. Auditing method according to any of claims 1 to 6, characterized in that the method further comprises:

8. The review method according to claim 7, wherein the analyzing the inferred diagnosis set corresponding to each operation in the operation information according to the disease category score database and the operation information comprises:

9. An examination device for the first page of a medical record, the device comprising:

10. A computer device comprising a memory, a processor and a computer program stored in the memory for execution, wherein the processor when executing the program performs the steps of the method for auditing the first pages of medical records according to any one of claims 1-8.

11. A computer-readable storage medium, characterized in that the computer-readable storage medium stores a computer program which, when being executed by a processor, carries out the steps of the examination method of the first page of a medical record according to any one of claims 1-8.