CN114724665A - BS version-based electronic medical record splitting method for multi-end written medical record - Google Patents
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- 238000000034 method Methods 0.000 title claims abstract description 28
- 238000004590 computer program Methods 0.000 claims description 15
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- 230000004048 modification Effects 0.000 abstract description 5
- 238000012986 modification Methods 0.000 abstract description 5
- 206010019233 Headaches Diseases 0.000 description 2
- 206010037660 Pyrexia Diseases 0.000 description 2
- 238000006062 fragmentation reaction Methods 0.000 description 2
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- 231100000869 headache Toxicity 0.000 description 2
- 208000002193 Pain Diseases 0.000 description 1
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- G16H10/00—ICT specially adapted for the handling or processing of patient-related medical or healthcare data
- G16H10/60—ICT specially adapted for the handling or processing of patient-related medical or healthcare data for patient-specific data, e.g. for electronic patient records
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Abstract
The invention relates to a BS version-based electronic medical record splitting method for a multi-end written medical record, and belongs to the field of medical informatization. The method comprises the following steps: s1: according to the content of patient complaints, a doctor enters a admission record to generate a medical record flow file and the relationship between medical records and data elements, and a template of a case is established; s2: storing and loading the templates of the case at the PC end and the mobile end respectively; when the doctor logs in again by using the mobile terminal, selecting a medical record, and acquiring all data elements in the medical record through a medical record ID in the relationship between the medical record and the data elements; binding the relationship between the medical record and the data element in a template of the mobile terminal in advance, assigning the relationship to a corresponding position of the mobile terminal through the data element code, and displaying the relationship; and after the mobile terminal modifies the main complaint, updating the relationship between the medical record and the data element. The medical record written on the PC side can be logged in to view and complete modification, review and annotation of partial data through a mobile side or other non-PC side application.
Description
Technical Field
The invention belongs to the field of medical informatization, and relates to an electronic medical record splitting method for a multi-end written medical record based on a BS version.
Background
At present, electronic medical records of a medical system are almost completely written, audited and printed before a computer, and related content of the medical records is not supported to be temporarily processed in various fragmentation time. If the medical records are not written on time, corresponding timeliness quality control is carried out to screen the medical records, the work performance of a doctor is affected seriously, and great inconvenience is brought to the work of the doctor. The function is specially formulated to meet the requirement that doctors can modify the medical records of patients at any time and the pain points.
Disclosure of Invention
In view of the above, the present invention is directed to a BS-version-based electronic medical record splitting method for a multi-end writing medical record.
In order to achieve the purpose, the invention provides the following technical scheme:
a BS version-based electronic medical record splitting method for a multi-end written medical record comprises the following steps:
s1: according to the content of patient complaints, a doctor enters a admission record to generate a medical record flow file and the relationship between medical records and data elements, and a template of a case is established;
s2: storing and loading the templates of the case at the PC end and the mobile end respectively; when the doctor logs in again by using the mobile terminal, selecting a medical record, and acquiring all data elements in the medical record through a medical record ID in the relationship between the medical record and the data elements; binding the relationship between the medical record and the data element in a template of the mobile terminal in advance, assigning the relationship to a corresponding position of the mobile terminal through the data element code, and displaying the relationship; and after the mobile terminal modifies the main complaint, updating the relation between the medical record and the data element.
Optionally, the template of the case comprises a data element part and a non-data element part;
the data element part comprises various indexes of the patient at the present visit;
the data element part is synchronously updated at multiple ends;
the non-data element portion includes an auxiliary description of a medical record; when the non-data element parts on the PC side and the mobile side are inconsistent, the PC side is taken as the standard.
Optionally, when the template of the case is stored at the PC end, unified encoding compression is performed;
all data element parts in the template of the medical record are stored independently;
the stored content comprises the basic attribute of the data element, and the basic attribute is used for displaying back to a medical record and finishing the rendering of a page when the data element is loaded;
the basic attributes of the data elements comprise data element codes, data element names, data element display modes and actual written values of the data elements in the current medical record;
wherein the data element presentation comprises text, drop-down, and date.
Optionally, when the mobile terminal loads the template of the case, the mobile terminal does not need to load the stream file of the PC terminal; the mobile end is provided with a self frame structure; the mobile terminal only loads all data elements under the current medical record, and the effect of presenting the data element value of the PC terminal at the mobile terminal is realized
When the mobile terminal stores the template of the case, the mobile terminal stores the relation table of the case history and the data element besides the JSON format frame flow of the case history of the mobile terminal; the table which is related to the stored medical record data element of the PC end comes from the same source;
when the PC side displays the template of the case, firstly loading the stream file of the PC side, and then synchronously refreshing the relation table of the medical record and the data element to obtain the value of the data element stored by the mobile side; the unified scheme of storing and displaying the data elements of the PC end and the mobile end is realized;
optionally, the calendar file includes a medical record ID, content of patient complaint, and creation time;
the relationship between the medical record and the data element comprises a medical record ID, a data element code, a data element type, a data element value and a creation time.
Optionally, after the mobile terminal modifies the main complaint, only the main complaint is modified, and the rest of data is unchanged;
when the PC end loads, the medical record stream file of the PC end is loaded firstly, then all data elements of the medical record are obtained, the latest data is stored in the relation between the medical record and the data elements, then the medical record ID is used for obtaining all the data elements of the medical record, then the values of the data elements in the medical record relation table are sequentially matched in the stream file of the PC end through analyzing the medical record content, and the medical record display of the PC end is completed.
Optionally, when there are multiple identical data elements in the template of the case, the second and subsequent identical data elements are processed in encoding to ensure that one data element encoding exists only once in one template, so as to avoid that one data element encoding of a case record has multiple data elements during storage, and avoid the wrong storage of different contents of the identical data elements.
A storage medium comprising a computer program, wherein the computer program is executed to execute the message sending method of multiple hospitals in internet medical treatment.
An electronic device, comprising:
a processor;
a memory including a computer program;
the processor is used for operating the computer program in the memory, and when the computer program is operated, the message sending method of the multiple hospitals in the internet diagnosis and treatment is executed.
The invention has the beneficial effects that:
1. the medical record written on the PC side can be logged in to view and complete modification, review and annotation of partial data through a mobile side or other non-PC side application.
2. Through the case history after the mobile terminal is modified, data synchronization can be completed with the electronic case history of the PC terminal in real time, namely, the electronic case history written by the mobile terminal can directly meet the requirements of printing and filing.
Additional advantages, objects, and features of the invention will be set forth in part in the description which follows and in part will become apparent to those having ordinary skill in the art upon examination of the following or may be learned from practice of the invention. The objectives and other advantages of the invention may be realized and attained by the means of the instrumentalities and combinations particularly pointed out hereinafter.
Drawings
For the purposes of promoting a better understanding of the objects, aspects and advantages of the invention, reference will now be made to the following detailed description taken in conjunction with the accompanying drawings in which:
FIG. 1 is a flow chart of the present invention.
Detailed Description
The embodiments of the present invention are described below with reference to specific embodiments, and other advantages and effects of the present invention will be easily understood by those skilled in the art from the disclosure of the present specification. The invention is capable of other and different embodiments and of being practiced or of being carried out in various ways, and its several details are capable of modification in various respects, all without departing from the spirit and scope of the present invention. It should be noted that the drawings provided in the following embodiments are only for illustrating the basic idea of the present invention in a schematic way, and the features in the following embodiments and examples may be combined with each other without conflict.
Wherein the showings are for the purpose of illustrating the invention only and not for the purpose of limiting the same, and in which there is shown by way of illustration only and not in the drawings in which there is no intention to limit the invention thereto; for a better explanation of the embodiments of the present invention, some parts of the drawings may be omitted, enlarged or reduced, and do not represent the size of an actual product; it will be understood by those skilled in the art that certain well-known structures in the drawings and descriptions thereof may be omitted.
The same or similar reference numerals in the drawings of the embodiments of the present invention correspond to the same or similar components; in the description of the present invention, it should be understood that if there is an orientation or positional relationship indicated by terms such as "upper", "lower", "left", "right", "front", "rear", etc., based on the orientation or positional relationship shown in the drawings, it is only for convenience of description and simplification of description, but it is not an indication or suggestion that the referred device or element must have a specific orientation, be constructed in a specific orientation, and be operated, and therefore, the terms describing the positional relationship in the drawings are only used for illustrative purposes, and are not to be construed as limiting the present invention, and the specific meaning of the terms may be understood by those skilled in the art according to specific situations.
Please refer to fig. 1, which is a method for splitting an electronic medical record based on BS version of a multi-end written medical record, and solves a problem of a doctor rapidly writing a medical record in a non-office area (at home, on-off duty, at a time of having a meal or other fragmentations).
The original frame of the medical record is from a template, which is composed of data elements and non-data elements. Therefore, the medical record content is divided into 2 large blocks of content, a data element part and a non-data element part. The data of the data element part is basically the description of each index of the patient at the current visit, and the data element part needs to be updated synchronously at multiple ends. The non-data element part is an auxiliary description part of the medical record and has the top-down connection with the content of the medical record. Real-time synchronization is not required. And the non-data element parts of the PC and the mobile terminal may not be consistent, but the whole medical history of the patient is not influenced. Only at the time of page rendering, there will be differences. And finally, printing the medical record discharged from the patient by taking the PC end as a standard.
When the PC side stores the medical records, the medical record contents are uniformly encoded and compressed, and the storage space is reduced. All data elements in the medical record need to be stored separately. And when the data elements are stored, all basic attributes of the data elements are stored, and when the data elements are used for loading, the data elements are displayed back in the medical records and the rendering of the page is completed. Such as data element encoding, data element name, data element presentation (text, drop-down, date, etc.), and the actual written value of the data element in the current medical record. In this way, if the mobile terminal needs to load, the stream file on the PC terminal does not need to be loaded, since they are likely not compatible with each other. The mobile end needs to have its own frame structure. The effect that the mobile terminal presents the data element value of the PC terminal can be realized only by loading all the data elements under the current medical record.
When the mobile end medical record is stored, besides storing the framework stream (usually in JSON format) of the mobile end medical record, a relationship table between the medical record and the data element is also stored. Namely, the table storing the medical record data element relation with the PC end comes from the same source. In this case. When the PC terminal displays, the stream file of the PC terminal is loaded first, and then the relation table of the medical record and the data element is synchronously refreshed. Thus, the value of the data element stored in the mobile terminal can be obtained. The scheme for realizing the unified storage and display of the data elements of the PC end and the mobile end is realized.
Taking the patient admission record as an example, how the medical record contents of the lower PC end and the mobile end are communicated is concretely explained.
When a patient is admitted, a doctor writes a admission record for the patient, if the patient complains that the patient has fever with headache for 3 days, a medical record stream file is generated when the patient is stored as a medical record, and meanwhile, the relationship between the medical record and a data element is generated. The medical record implements a one-to-many relationship with the data elements in the medical record. The medical record stream, the medical record and the element relationship table are shown in the following tables 1 and 2:
TABLE 1 case flow
TABLE 2 medical records and element relationship Table
After the storage, when the doctor logs in again with the mobile terminal, the doctor selects the medical record, and can directly obtain all data elements in the medical record through the medical record ID (ID _001 in the present case) in the medical record relation table, and then the name and the chief complaint are obtained in the present case, so that the relationship and the position of the name and the chief complaint can be bound in advance in the template of the mobile terminal, and thus the name and the chief complaint can be assigned to the corresponding position of the mobile terminal through data element coding, namely that the patient is Zhang III, and the chief complaint is fever with headache for 3 days. Thereby achieving the purpose of display.
After the mobile terminal modifies the chief complaint, the content of the stream file on the PC terminal is not affected, and only the relationship table between the medical record and the data element is updated, as shown in table 3.
TABLE 3 medical record and data element relationship update Table
After modification, only the record is complained of being modified. The remaining data is unchanged. When the PC side loads, the PC side first loads the medical record stream file, and then acquires all data elements of the medical record, because in this case, although the PC side stream file can be displayed, the PC side stream file is not actually the latest data of the medical record. The latest data is stored in a relation table of medical records and data elements. At this time, all data elements of the medical record are obtained by using the medical record ID, and then the values of the data elements in the medical record relation table are matched to the stream file of the PC end in a circulating manner in the stream file of the PC end by analyzing the content of the medical record, so that the medical record display of the PC end is completed.
The medical record is generated through a template, wherein the template consists of a plurality of data elements, and each data element represents a certain business meaning. The data elements have different display modes of text, drop-down, multi-selection and the like. When a plurality of identical data elements exist in one template, the second and the following identical data elements are processed on the codes, and one data element code is ensured to exist in one template only once, so that the condition that a plurality of data element codes of a medical record exist in the time of storage is avoided. Erroneous storage of different contents of the same data element is also avoided.
It should be recognized that embodiments of the present invention can be realized and implemented by computer hardware, a combination of hardware and software, or by computer instructions stored in a non-transitory computer readable memory. The methods may be implemented in a computer program using standard programming techniques, including a non-transitory computer-readable storage medium configured with the computer program, where the storage medium so configured causes a computer to operate in a specific and predefined manner, according to the methods and figures described in the detailed description. Each program may be implemented in a high level procedural or object oriented programming language to communicate with a computer system. However, the program(s) can be implemented in assembly or machine language, if desired. In any case, the language may be a compiled or interpreted language. Furthermore, the program can be run on a programmed application specific integrated circuit for this purpose.
Further, the operations of processes described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The processes described herein (or variations and/or combinations thereof) may be performed under the control of one or more computer systems configured with executable instructions, and may be implemented as code (e.g., executable instructions, one or more computer programs, or one or more applications) collectively executed on one or more processors, by hardware, or combinations thereof. The computer program includes a plurality of instructions executable by one or more processors.
Further, the method may be implemented in any type of computing platform operatively connected to a suitable connection, including but not limited to a personal computer, mini computer, mainframe, workstation, networked or distributed computing environment, separate or integrated computer platform, or in communication with a charged particle tool or other imaging device, or the like. Aspects of the invention may be embodied in machine-readable code stored on a non-transitory storage medium or device, whether removable or integrated into a computing platform, such as a hard disk, optically read and/or write storage medium, RAM, ROM, or the like, such that it may be read by a programmable computer, which when read by the storage medium or device, is operative to configure and operate the computer to perform the procedures described herein. Further, the machine-readable code, or portions thereof, may be transmitted over a wired or wireless network. The invention described herein includes these and other different types of non-transitory computer-readable storage media when such media include instructions or programs that implement the steps described above in conjunction with a microprocessor or other data processor. When the method for splitting the electronic medical record based on the BS version multi-end written medical record and the technical programming are adopted, the invention also comprises the computer per se.
A computer program can be applied to input data to perform the functions described herein to transform the input data to generate output data that is stored to non-volatile memory. The output information may also be applied to one or more output devices, such as a display. In a preferred embodiment of the invention, the transformed data represents physical and tangible objects, including particular visual depictions of physical and tangible objects produced on a display.
Finally, although the present invention has been described in detail with reference to the preferred embodiments, it should be understood by those skilled in the art that various changes and modifications may be made therein without departing from the spirit and scope of the invention as defined by the appended claims.
Claims (9)
1. A BS version-based electronic medical record splitting method for multi-end written medical records is characterized in that: the method comprises the following steps:
s1: according to the content of patient complaints, a doctor enters a admission record to generate a medical record flow file and the relationship between medical records and data elements, and a template of a case is established;
s2: storing and loading the templates of the case at the PC end and the mobile end respectively; when the doctor logs in again by using the mobile terminal, selecting a medical record, and acquiring all data elements in the medical record through a medical record ID in the relationship between the medical record and the data elements; binding the relationship between the medical record and the data element in a template of the mobile terminal in advance, assigning the relationship to a corresponding position of the mobile terminal through the data element code, and displaying the relationship; and after the mobile terminal modifies the main complaint, updating the relationship between the medical record and the data element.
2. The method for splitting the electronic medical record based on the BS version of the multi-end written medical record as claimed in claim 1, wherein: the template of the case includes a data element portion and a non-data element portion;
the data element part comprises various indexes of the patient at the present visit;
the data element part is synchronously updated at multiple ends;
the non-data element portion includes an auxiliary description of a medical record; when the non-data element parts on the PC side and the mobile side are inconsistent, the PC side is taken as the standard.
3. The method for splitting the electronic medical record based on the BS version of the multi-end written medical record as claimed in claim 1, wherein: when the template of the case is stored at the PC end, unified coding compression is carried out;
all data element parts in the template of the medical record are stored independently;
the stored content comprises the basic attribute of the data element, and the basic attribute is used for displaying back to a medical record and finishing the rendering of a page when the data element is loaded;
the basic attributes of the data elements comprise data element codes, data element names, data element display modes and actual written values of the data elements in the current medical record;
wherein the data element presentation comprises text, drop-down, and date.
4. The method for splitting the electronic medical record of the multi-end written medical record based on the BS version according to claim 1, wherein: when the mobile terminal loads the template of the case, the stream file of the PC terminal does not need to be loaded; the mobile end is provided with a self frame structure; the mobile terminal only loads all data elements under the current medical record, and the effect of presenting the data element value of the PC terminal at the mobile terminal is realized
When the mobile terminal stores the template of the case, the mobile terminal stores the relation table of the case history and the data element besides the JSON format frame flow of the case history of the mobile terminal; the table which is in the metadata relation with the stored medical record data at the PC end comes from the same source;
when a PC terminal displays a template of a case, a stream file of the PC terminal is loaded at first, and then a relation table of a medical record and a data element is synchronously refreshed to obtain a value of the data element stored by a mobile terminal; the unified scheme of storing and displaying the data elements of the PC end and the mobile end is realized;
5. the method for splitting the electronic medical record of the multi-end written medical record based on the BS version according to claim 1, wherein: the calendar flow file comprises a medical record ID, the content of patient chief complaints and creation time;
the relationship between the medical record and the data element comprises a medical record ID, a data element code, a data element type, a data element value and a creation time.
6. The method for splitting the electronic medical record based on the BS version of the multi-end written medical record as claimed in claim 5, wherein: after the mobile terminal modifies the main complaint, only the main complaint is modified, and the rest data are unchanged;
when the PC end loads, the medical record stream file of the PC end is loaded firstly, then all data elements of the medical record are obtained, the latest data is stored in the relation between the medical record and the data elements, then the medical record ID is used for obtaining all the data elements of the medical record, then the values of the data elements in the medical record relation table are sequentially matched in the stream file of the PC end through analyzing the content of the medical record in the stream file of the PC end, and thus the medical record display of the PC end is completed.
7. The method for splitting the electronic medical record based on the BS version of the multi-end written medical record as claimed in claim 6, wherein: when the template of the case has a plurality of the same data elements, the second and the following same data elements are processed on the codes so as to ensure that one data element code only exists once in one template, thereby avoiding that one data element code of one medical record has a plurality of data element codes during storage and avoiding the error storage of different contents of the same data elements.
8. A storage medium comprising a computer program, wherein the computer program is executed to execute the method for sending messages of multiple hospitals in internet medical care according to any one of claims 1 to 7.
9. An electronic device, comprising:
a processor;
a memory including a computer program;
the processor is configured to run a computer program in the memory, and when the computer program runs, the processor executes the message sending method for multiple hospitals in internet medical treatment according to any one of claims 1 to 7.
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| CN115983228A (en) * | 2022-12-28 | 2023-04-18 | 北京欧应科技有限公司 | Method, system, computing device and storage medium for generating medical record templates |
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