CN114882966A - Electronic medical record generation method, device, equipment, medium and product - Google Patents
Electronic medical record generation method, device, equipment, medium and product Download PDFInfo
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Abstract
The present disclosure provides a method, an apparatus, a device, a medium, and a product for generating an electronic medical record, where the method includes: acquiring a medical record template corresponding to a department attribute of a user identifier, wherein the medical record template comprises element components and preset medical record description data corresponding to the element components; acquiring patient medical record data generated based on the element component and the preset medical record description data; verifying the accuracy of the patient medical record data; in a case that the patient medical record data is determined to be accurate, an electronic medical record is generated based on the patient medical record data. The method and the device are used for solving the defects that the generation of the electronic medical record in the prior art is long in time consumption and multiple in problems, and the electronic medical record can be generated quickly and accurately.
Description
Technical Field
The present disclosure relates to the field of smart medical technology, and in particular, to a method, an apparatus, a device, a medium, and a product for generating an electronic medical record.
Background
In the medical industry, writing of medical records is a task that medical personnel are often faced with. In the prior art, a medical record template is single, only comprises fixed elements such as chief complaints, current medical history and allergic history, and needs medical personnel to perform long-time character input according to the actual condition of a patient. Because medical personnel are required to input a large amount of characters, the condition of inputting errors can be caused. However, after the text is entered, the medical staff directly stores the text, and the defect of entering the text cannot be determined, so that the finally generated electronic medical record may have problems.
Disclosure of Invention
The present disclosure provides a method, an apparatus, a device, a medium, and a product for generating an electronic medical record, so as to solve the defects of long time consumption and many problems in generating an electronic medical record in the prior art, and realize rapid and accurate generation of an electronic medical record.
The present disclosure provides a method for generating an electronic medical record, including:
acquiring a medical record template corresponding to a department attribute of a user identifier, wherein the medical record template comprises element components and preset medical record description data corresponding to the element components;
acquiring patient medical record data generated based on the element component and the preset medical record description data;
verifying the accuracy of the patient medical record data;
in a case that the patient medical record data is determined to be accurate, an electronic medical record is generated based on the patient medical record data.
According to the generation method of the electronic medical record provided by the present disclosure, the patient medical record data includes: the filled element components and the medical record description data corresponding to the filled element components;
the verifying the accuracy of the patient medical record data comprises:
acquiring the filled-in element components in the patient medical record data;
judging whether medical record description data corresponding to the filled element assembly carrying the necessary filling mark is empty or not to obtain a judgment result;
and under the condition that the filled element components are determined to be consistent with the element components and the judgment result is not null, determining that the patient medical record data is accurate.
According to the generation method of the electronic medical record provided by the present disclosure, the verifying the accuracy of the patient medical record data includes:
acquiring preset incidence relation among the element assemblies;
identifying the legality of the medical record description data based on the incidence relation;
and determining that the patient medical record data is accurate under the condition that the medical record description data is determined to be legal.
According to a method for generating an electronic medical record provided by the present disclosure, the acquiring a medical record template corresponding to a department attribute of a user identifier includes:
acquiring a template identifier corresponding to the department attribute of the user identifier;
acquiring an initial medical record template corresponding to the template identifier;
acquiring the information of the patient at the current moment;
and loading the visit information into the initial medical record template to obtain a medical record template corresponding to the patient.
According to a generation method of an electronic medical record provided by the present disclosure, the acquiring patient medical record data generated based on the element component and the preset medical record description data includes:
and acquiring patient medical record data obtained by modifying the preset medical record description data corresponding to the element assembly.
According to the generation method of the electronic medical record provided by the present disclosure, after the electronic medical record is generated, the method further includes:
acquiring target patient medical record data corresponding to a target filled element assembly corresponding to at least one patient;
determining a new diagnostic plan for the patient based on the target patient medical record data.
The present disclosure also provides an apparatus for generating an electronic medical record, including:
the medical record system comprises a first acquisition module, a second acquisition module and a third acquisition module, wherein the first acquisition module is used for acquiring a medical record template corresponding to the department attribute of a user identifier, and the medical record template comprises element components and preset medical record description data corresponding to the element components;
the second acquisition module is used for acquiring patient medical record data generated based on the element assembly and the preset medical record description data;
the verification module is used for verifying the accuracy of the patient medical record data;
and the generating module is used for generating the electronic medical record based on the patient medical record data under the condition that the patient medical record data is determined to be accurate.
The present disclosure also provides an electronic device, which includes a memory, a processor, and a computer program stored in the memory and executable on the processor, and when the processor executes the program, the processor implements the method for generating an electronic medical record as described in any of the above.
The present disclosure also provides a non-transitory computer-readable storage medium having stored thereon a computer program which, when executed by a processor, implements the method of generating an electronic medical record as described in any of the above.
The present disclosure also provides a computer program product comprising a computer program which, when executed by a processor, implements the method for generating an electronic medical record as described in any of the above.
According to the method, the device, the equipment, the medium and the product for generating the electronic medical record, a medical record template corresponding to the department attribute of the user identifier is obtained, and the medical record template comprises element components and preset medical record description data corresponding to the element components; therefore, the medical record template is determined based on the department attributes, and the medical record templates are different due to the different department attributes, so that the information input of medical staff can be effectively reduced, and the text input duration and the text input error rate are reduced compared with the single medical record template in the prior art; the patient medical record data generated based on the element assemblies and the preset medical record description data is acquired, so that the medical staff does not need to record the content of each element assembly, the patient medical record data can be generated based on the preset medical record description data, and the text entry time is shortened; further, the accuracy of the patient medical record data is verified; under the condition that the patient medical record data is determined to be accurate, the electronic medical record is generated based on the patient medical record data, and therefore the electronic medical record can be generated under the condition that the patient medical record data is determined to be accurate, the accuracy of the patient medical record data is guaranteed, and finally the electronic medical record can be generated quickly and accurately.
Drawings
In order to more clearly illustrate the technical solutions of the present disclosure or the prior art, the drawings needed for the description of the embodiments or the prior art will be briefly described below, and it is obvious that the drawings in the following description are some embodiments of the present disclosure, and other drawings can be obtained by those skilled in the art without creative efforts.
Fig. 1 is a schematic flow chart diagram of a method for generating an electronic medical record provided by the present disclosure;
fig. 2 is a second schematic flowchart of a method for generating an electronic medical record provided by the present disclosure;
fig. 3 is a third schematic flow chart of a method for generating an electronic medical record provided by the present disclosure;
fig. 4 is a fourth schematic flowchart of a method for generating an electronic medical record provided by the present disclosure;
fig. 5 is a fifth flowchart of a method for generating an electronic medical record provided by the present disclosure;
FIG. 6 is a schematic diagram of an electronic medical record framework provided by the present disclosure;
fig. 7 is a schematic structural diagram of an apparatus for generating an electronic medical record provided by the present disclosure;
fig. 8 is a schematic structural diagram of an electronic device provided by the present disclosure.
Detailed Description
In order to make the objects, technical solutions and advantages of the embodiments of the present disclosure more clear, the technical solutions of the embodiments of the present disclosure will be described clearly and completely with reference to the drawings in the embodiments of the present disclosure, and it is obvious that the described embodiments are some, but not all, of the embodiments of the present disclosure. All other embodiments, which can be obtained by a person skilled in the art without making creative efforts based on the embodiments of the present disclosure, belong to the protection scope of the embodiments of the present disclosure.
The method for generating an electronic medical record according to the embodiment of the disclosure is described below with reference to fig. 1 to 5.
Some terms used in the present disclosure are explained below in detail:
element assembly: fields in a medical record writing interface;
presetting medical record description data: descriptive statements explaining the medical records also include default values;
patient medical record data: visit data generated when the patient visits a doctor;
electronic Medical Records (EMR) are also known as computerized Medical Record systems or Computer-Based Patient records (CPR). It is a digitalized medical record stored, managed, transmitted and reproduced by electronic equipment (computer, health card, etc.) to replace the hand-written paper case history. Its contents include all the information of the paper case history.
Specifically, the user of the present disclosure may be a medical staff, and the medical staff enters the medical record writing interface by using a terminal device of the doctor end, and inputs and stores medical record data of the patient based on several fixed elements in the interface, such as chief complaints, current medical history, and allergy history.
Specifically, in the prior art, a single template is adopted, and the template only comprises a few fixed elements, so that when a medical worker enters a character, in addition to time consumption, other problems can be encountered, for example, element fixation, namely fixation of medical record writing content items, is not easy to expand, and content items cannot be dynamically added; as another example, a medical worker is required to enter a large amount of text; as another example, medical record content utilization is low; for another example, medical record data cannot be automatically reviewed; and the like.
In addition, due to different requirements of different hospitals, codes are required to be modified to change the medical record writing interface of the terminal so as to adapt to different hospitals. For example, hospital a only needs several elements of chief complaints, current medical history and historical history, while hospital B also needs treatment opinion elements, which requires code modification, is time-consuming, costly and has poor user experience.
In addition, in the prior art, the electronic medical records are not checked when the electronic medical records are produced, but because medical workers input a large amount of characters, the situations of wrongly written characters or wrong medical record data can occur, and the generated electronic medical records have many problems. For example, the sex of the patient is male, but the content of the menstrual history appears in the medical history data.
In addition, the existing electronic medical record has low utilization rate, and the utilization value of medical record data is reduced.
In order to effectively solve the above problem, the embodiments of the present disclosure provide a method for generating an electronic medical record, where the method may be applied to an intelligent terminal, such as a mobile phone, a computer, a tablet, and the like, and may also be applied to a server. The method is applied to a server as an example, but it should be noted that the method is only an example and is not intended to limit the scope of the present disclosure. In addition, it should be noted that, in the embodiment of the present disclosure, the information of the electronic medical record of the patient is obtained and processed under the condition that the patient, the hospital, and the like know and agree, and the information complies with the relevant laws and regulations. Some other descriptions in the embodiments of the present disclosure are also for illustration and are not intended to limit the scope of the present disclosure, and will not be described any more. The specific implementation of the method is shown in fig. 1:
The medical record template comprises element components and preset medical record description data corresponding to the element components.
Wherein, the department attribute includes: the department that belongs to hospital, medical characteristics based on confirm to and each department's department that corresponds, wherein, the department includes: the department of living, the outpatient department, etc., wherein, the department includes: respiratory, digestive, medical, surgical, pediatric, etc.
Specifically, before acquiring the medical record module, a medical record template needs to be set. And specifically, establishing a medical record template according to the actual conditions of all the hospitals. Wherein, each hospital corresponds to a set of medical record templates. Of course, when different hospitals have the same actual conditions, a set of medical record templates can be shared. The set of medical record templates comprises at least two versions of medical record templates, wherein one version corresponds to a department of living, and the other version corresponds to a department of outpatient service. The medical record template comprises a plurality of medical record templates, one department corresponds to one medical record template, and each medical record template is provided with a template identifier which can be uniquely represented. The disclosure is an angular schedule of a patient standing on a medical record template.
Specifically, each medical record template is set based on the actual situation of the department, that is, the element component of each medical record template and the preset medical record description data corresponding to the element component are set based on the actual situation of the department.
Wherein each element component comprises a tag type, the tag type comprising: single selection, multiple selection, text, etc.
When the label type of the element assembly is a text, the preset medical record description data is a statement which is counted in advance and is commonly used by a corresponding department, such as drinking hot water more, doing sports more, not eating too much, and the like. When the label type of the element assembly is single-choice or multi-choice, the preset medical record description data is a common result obtained after statistical analysis is carried out on historical medical record data of a large number of patients.
Specifically, the preset medical record description data is a default value of the element component.
According to the method and the device, the medical record templates of different departments of different hospitals are created in advance, so that the differentiation of different medical record templates is guaranteed, an effective data base is provided for the subsequent generation of the electronic medical record, the time for generating the electronic medical record is shortened, the efficiency for generating the electronic medical record is improved, and the user experience is improved.
In addition, when a new department is added, a medical record template corresponding to the new department is directly created without modifying codes. Moreover, when a certain department needs to add a certain element newly, an element component is directly added in the medical record template corresponding to the department without modifying codes. Or, when the user thinks that the preset medical record description data corresponding to the element components in the template has problems, the preset medical record description data can be directly modified on the corresponding medical record template.
By adopting the smooth expansion mode, convenience and customization of electronic medical record generation are guaranteed, a user can modify the template based on own requirements, user experience is improved, and labor cost is saved.
In one embodiment, the obtaining of the medical record model is implemented as follows: acquiring a template identifier corresponding to the department attribute of the user identifier; acquiring an initial medical record template corresponding to the template identifier; acquiring the information of the patient at the current moment; and loading the information of seeing a doctor into the initial medical record template to obtain a medical record template corresponding to the patient.
Wherein the user identification is a unique number of the doctor.
Specifically, the hospital and department to which the medical staff belongs can be obtained through the user identifier, the template identifier corresponding to the hospital and department is obtained based on the hospital and department to which the medical staff belongs, and an initial medical record template is obtained, wherein the initial medical record template at the moment is a medical record template created before. After the initial medical record template is obtained, the obtained treatment information of the patient is loaded into the initial medical record template to obtain a medical record module, the medical record template at this time is not the medical record template created before, but the medical record template after the treatment information of the patient is loaded, and then the medical record templates mentioned in the description of the disclosure are all the medical record templates after the treatment information of the patient is loaded.
Wherein, the information of seeing a doctor includes: patient identity information and patient need information, for example, identity information includes: the identity, name, age and sex of the patient, and the like, and the requirement information of the patient includes: the patient's visit, the doctor and the time of the visit, etc.
Specifically, after the registration appointment of the patient, a patient card or a two-dimensional code is provided, and the patient information is obtained by identifying the patient card or the two-dimensional code.
Wherein, the information of seeing a doctor still includes: historical medical record data for the patient.
In addition, whether the patient is the first visit is determined based on the identity information of the patient, the identity information and the demand information of the patient are loaded to the initial medical record template when the patient is determined to be the first visit, and the identity information, the demand information and the historical medical record data of the patient are loaded to the initial medical record template when the patient is determined not to be the first visit. The initial medical record templates corresponding to the patients who are not treated for the first time are more than the initial medical record templates corresponding to the patients who are treated for the first time, and element components capable of loading historical medical record data exist.
This is disclosed through the mode of automatic loading information of seeing a doctor to initial case history template to obtain final case history template, need not medical personnel artificial manual input, reduced medical personnel's work load, it is long when having practiced thrift the seeing a doctor, improved user experience.
In one embodiment, patient medical record data obtained by modifying preset medical record description data corresponding to the element component is obtained.
And presetting the medical record description data as data which is filled in advance when the label type of the element assembly is a text label. Of course, a tag type of single-choice tag or multiple-choice tag would also provide a default value.
Specifically, the medical record writing interface of the App loads the element component by reading the element component and the tag type in the medical record template in the XML format, displays the name of the element component, displays the corresponding style of the element component based on the different tag types of the element component, and displays the default value set by the element component.
The preset medical record description data is obtained based on the field specialties of departments and doctors and the historical medical record data of a large number of patients, so that medical personnel can obtain the medical record data of the patients by modifying the preset medical record description data without inputting a large number of characters.
This is disclosed need not medical personnel and types a large amount of literal information, can change the investigation operation through increasing to predetermineeing case history description data, alright in order to obtain final patient's case history data, reduced medical personnel's work load, improved data entry efficiency, reduced the error rate of patient's case history data, improved the accuracy of patient's case history data, it is long when having practiced thrift the seeing a doctor, improved user experience.
And 103, verifying the accuracy of the patient medical record data.
Specifically, after the medical staff records the patient medical record data of the patient based on the medical record writing interface, the medical staff clicks a storage button of the medical record writing interface, a verification instruction is generated at the moment, and the server verifies the accuracy of the patient medical record data after receiving the verification instruction. When the patient medical record data is determined to be accurate, returning a mark of successful verification and storing the patient medical record data; and when the patient medical record data is determined to be inaccurate, returning a mark of verification failure, and simultaneously returning the component identification and the problem reason of the component element with the problem so that the medical record writing interface displays the component element with the problem and the problem reason. Medical personnel can revise the data of typing in based on subassembly element and the problem reason that the medical record writes the problem that the interface displayed, and then click once more and save the button to save patient's medical record data.
According to the method and the device, the accuracy of the patient medical record data is ensured by verifying the accuracy of the patient medical record data, and a favorable data base is provided for subsequent research and analysis according to the patient medical record data.
In one embodiment, the patient medical record data includes: the filled element components and the medical record description data corresponding to the filled element components; specifically, filled element components in patient medical record data are obtained; judging whether medical record description data corresponding to the filled element assembly carrying the necessary filling mark is empty or not to obtain a judgment result; and under the condition that the filled element components are consistent with the element components and the judgment result is not empty, determining that the medical record data of the patient is accurate.
Specifically, the specific implementation of determining the accuracy of the patient medical record data includes the following two determination modes:
the first way of determination is shown in fig. 2:
step 201, comparing the filled element components with the element components to obtain a comparison result, and judging whether medical record description data corresponding to the filled element components carrying the necessary filling marks are empty to obtain a judgment result;
and step 203, determining that the medical record data of the patient is accurate when the comparison result and the judgment result are both qualified.
Wherein, the comparison result comprises: the filled-in element component is consistent with the element group, and the filled-in element component is inconsistent with the element component; the judgment result comprises: the case history description data corresponding to the filled element component is null, and the case history description data corresponding to the filled element component is not null.
Wherein the qualified standards are determined as follows: the filled element components and the element groups are consistent, and the medical record description data corresponding to the filled element components is not empty.
The second way of determining is shown in fig. 3:
Specifically, the method for verifying the accuracy of the patient medical record data provided by the embodiment can be defined as a method for verifying the integrity of the data.
Specifically, the specific verification logic of the data integrity verification mode is as follows: the system presets template identification of the medical record template, and binds the medical record template with the required element components through the template identification. And after a medical record document is created based on the medical record template, searching the bound element component list through the medical record template corresponding to the medical record document, and checking whether all bound element components exist in the medical record document. And, whether the element assemblies in the medical record document are completely filled is checked, so that the completeness check of the medical record document is finished
The medical record document is the file obtained by filling the treatment information of the patient based on the medical record template and adding or modifying the medical staff for the treatment, and is equivalent to the medical record data of the patient.
The present disclosure avoids loss of information by comparing the filled-in element components to match the element components in the medical record template to determine the integrity of the filled-in element components. And moreover, whether the medical record description data of the filled element assembly is empty or not is determined, and only under the condition of non-empty, the medical record data of the patient is determined to be qualified, so that the information loss is effectively avoided.
In a specific embodiment, association relations among preset element assemblies are obtained; identifying the legality of the medical record description data based on the association relation; and determining that the patient medical record data is accurate under the condition that the medical record description data is determined to be legal.
Specifically, the association relationship between the element components can be illustrated by several examples: for example, the relationship between gender and the menstruation history component, wherein when gender is male, the menstruation history component in the patient medical record data should not have information, and when gender is female, the menstruation history component in the patient medical record data should have information; for another example, no matter how many the eye degrees are, the myopia component in the patient medical record data should have information, and the information corresponding to the myopia component may be non-myopia, mild myopia, moderate myopia, high myopia, and the like.
Specifically, the method for verifying the accuracy of the patient medical record data provided by this embodiment may be defined as a verification method for mutual exclusivity of data.
The specific service logic is as follows: and creating a mutual exclusion rule, and selecting the application range of the rule, wherein the rule can be applied to a specified medical record template and can also be applied to all medical record templates.
Specifically, the specific validation logic of the data mutual exclusivity validation mode is as follows: the mutual exclusion rule satisfies the condition value of corresponding element component condition type if the element component condition type condition value is specified. The condition types include "present", "absent", "greater than", "less than", "equal to", and the like.
And a complete logic rule judgment is carried out through the mutual exclusion rule, and the verification of the mutual exclusivity of the data can be completed. For example: "if the gender component is equal to a male, then the menstrual history component is not present", then the addition of the menstrual history component to a male patient may be limited, or if the eye power component is present, then the myopia component is present, for example.
According to the method and the device, invalid data are filtered through mutual exclusion verification of the patient medical record data, the accuracy of the data is effectively guaranteed, and an effective data basis is provided for follow-up data research.
When the medical record data of the patient is verified, only a verification mode of data integrity may be adopted, only a verification mode of data mutual exclusivity may be adopted, both the verification modes may be adopted, and the following description will be given by taking both the verification modes as examples:
specifically, the specific implementation of determining the accuracy of the patient medical record data includes the following two determination modes:
the third way of determining is shown in fig. 4:
and step 403, determining that the medical record data of the patient is accurate when the verification results of the patient and the patient are both qualified.
The third way of determining is shown in fig. 5:
The method and the device adopt a verification mode based on data integrity and a verification mode based on data mutual exclusivity to verify the medical record data of the patient, and improve the accuracy of the medical record data of the patient.
And 104, under the condition that the medical record data of the patient is determined to be accurate, generating the electronic medical record based on the medical record data of the patient.
In one embodiment, after generating an electronic medical record, target patient medical record data corresponding to a target filled-in element component corresponding to at least one patient is obtained; based on the target patient medical record data, a new patient's diagnosis plan is determined.
Wherein the target filled-in component is at least one filled-in element component.
For example, the target filled-in element components are a smoking history component, a lung condition component, a smoking amount component, and the like, target patient medical record data corresponding to the smoking history component, the lung condition component, and the smoking amount component are respectively acquired, and a new treatment suggestion of the patient is generated by analyzing the target patient medical record data.
According to the method and the device, the structured medical record data are analyzed, so that effective treatment opinions are provided for new patients, and the utilization value of the medical record data of the patients is improved.
An embodiment of the present disclosure further provides a framework for generating an electronic medical record, as shown in fig. 6, the framework includes: a medical record writing layer 601, a business processing layer 602 and a data storage layer 603.
The medical record writing layer 601 is used for calling a medical record template to obtain a medical record document;
a business processing layer 602 for initializing a medical record template, and verifying and analyzing patient medical record data;
and the data storage layer 603 is used for storing medical record templates and patient medical record data.
The medical record writing layer 601 is a core part for medical record structured writing, and a medical record template is dynamically loaded through a structured template engine; and loading the corresponding element components according to the component identifiers in the medical record template, configuring and displaying the operation content interface which is visualized for a doctor according to the components, calling a service interface through the macro element to acquire the treatment information of the patient, and filling the treatment information into the initial medical record template to obtain a final medical record template so as to enable medical staff to use the medical record template.
And the business processing layer 602 is a core part for the content operation of the medical record document, provides service for the medical record writing layer 601, and processes data generated by the medical record writing layer 601. The method comprises the following steps: loading of medical record templates, acquisition of medical record macro-element content, data integrity verification of patient medical record data, mutual exclusion verification of patient medical record data, analysis of target patient medical record data, and the like.
And a data storage layer 603, which is a storage part for data, and stores medical record templates, patient medical record data and target patient medical record data.
According to the method for generating the electronic medical record, a medical record template corresponding to the department attribute of the user identifier is obtained, and the medical record template comprises element components and preset medical record description data corresponding to the element components; therefore, the medical record template is determined based on the department attributes, and the medical record templates are different due to the different department attributes, so that the information input of medical staff can be effectively reduced, and the text input duration is reduced compared with the medical record template which is single in the prior art; the patient medical record data generated based on the element assemblies and the preset medical record description data is acquired, so that the medical staff does not need to record the content of each element assembly, the patient medical record data can be generated based on the preset medical record description data, and the text entry time is shortened; further, the accuracy of the patient medical record data is verified; under the condition that the patient medical record data is determined to be accurate, the electronic medical record is generated based on the patient medical record data, and therefore the electronic medical record can be generated under the condition that the patient medical record data is determined to be accurate, the accuracy of the patient medical record data is guaranteed, and finally the electronic medical record can be generated quickly and accurately.
The following describes an electronic medical record generation apparatus provided in the embodiment of the present disclosure, and the electronic medical record generation apparatus described below and the electronic medical record generation method described above may be referred to correspondingly, and repeated parts are not described again, as shown in fig. 7, the apparatus includes:
a first obtaining module 701, configured to obtain a medical record template corresponding to a department attribute of a user identifier, where the medical record template includes element components and preset medical record description data corresponding to the element components;
a second obtaining module 702, configured to obtain patient medical record data generated based on the element component and the preset medical record description data;
a verification module 703 for verifying accuracy of patient medical record data;
a generating module 704 configured to generate an electronic medical record based on the patient medical record data if it is determined that the patient medical record data is accurate.
In one embodiment, the patient medical record data includes: the filled element assemblies and the medical record description data corresponding to the filled element assemblies; a verification module 703, specifically configured to obtain filled-in element components in patient medical record data; judging whether medical record description data corresponding to the filled element assembly carrying the necessary filling mark is empty or not to obtain a judgment result; and under the condition that the filled element components are consistent with the element components and the judgment result is not empty, determining that the medical record data of the patient is accurate.
In a specific embodiment, the verification module 703 is specifically configured to obtain an association relationship between preset element components; identifying the legality of the medical record description data based on the association relation; and determining that the patient medical record data is accurate under the condition that the medical record description data is determined to be legal.
In a specific embodiment, the first obtaining module 701 is specifically configured to obtain a template identifier corresponding to a department attribute of a user identifier; acquiring an initial medical record template corresponding to the template identifier; acquiring the information of the patient at the current moment; and loading the seeing-doctor information into the initial medical record template to obtain a medical record template corresponding to the patient.
In a specific embodiment, the second obtaining module 702 is specifically configured to obtain patient medical record data obtained by modifying preset medical record description data corresponding to the element component.
In one embodiment, the apparatus further comprises: the analysis module is used for acquiring target patient medical record data corresponding to the target filled-in element component corresponding to at least one patient; based on the target patient medical record data, a new patient's diagnosis plan is determined.
Fig. 8 illustrates a physical structure diagram of an electronic device, and as shown in fig. 8, the electronic device may include: a processor (processor)801, a communication Interface (Communications Interface)802, a memory (memory)803 and a communication bus 804, wherein the processor 801, the communication Interface 802 and the memory 803 complete communication with each other through the communication bus 804. The processor 801 may call logic instructions in the memory 803 to perform a method of generating an electronic medical record, the method comprising: acquiring a medical record template corresponding to the department attribute of the user identifier, wherein the medical record template comprises element components and preset medical record description data corresponding to the element components; acquiring patient medical record data generated based on the element components and preset medical record description data; verifying the accuracy of the patient medical record data; in the event that the patient medical record data is determined to be accurate, an electronic medical record is generated based on the patient medical record data.
In addition, the logic instructions in the memory 803 may be implemented in the form of software functional units and stored in a computer readable storage medium when the logic instructions are sold or used as independent products. Based on such understanding, the technical solutions of the embodiments of the present disclosure may be embodied in the form of a software product, which is stored in a storage medium and includes several 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 methods described in the embodiments of the present disclosure. 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.
In another aspect, the present disclosure also provides a computer program product, the computer program product including a computer program stored on a non-transitory computer-readable storage medium, the computer program including program instructions, when the program instructions are executed by a computer, the computer being capable of executing the method for generating an electronic medical record provided by the above methods, the method including: acquiring a medical record template corresponding to the department attribute of the user identifier, wherein the medical record template comprises element components and preset medical record description data corresponding to the element components; acquiring patient medical record data generated based on the element components and preset medical record description data; verifying the accuracy of the patient medical record data; in the event that the patient medical record data is determined to be accurate, an electronic medical record is generated based on the patient medical record data.
In yet another aspect, the present disclosure also provides a non-transitory computer-readable storage medium having stored thereon a computer program, which when executed by a processor is implemented to perform the method for generating an electronic medical record provided in the above aspects, the method including: acquiring a medical record template corresponding to the department attribute of the user identifier, wherein the medical record template comprises element components and preset medical record description data corresponding to the element components; acquiring patient medical record data generated based on the element components and preset medical record description data; verifying the accuracy of the medical record data of the patient; in the event that the patient medical record data is determined to be accurate, an electronic medical record is generated based on the patient medical record data.
The above-described embodiments of the apparatus are merely illustrative, and the units described as separate parts may or may not be physically separate, and parts displayed as units may or may not be physical units, may be located in one place, or may be distributed on a plurality of network units. Some or all of the modules may be selected according to actual needs to achieve the purpose of the solution of the present embodiment. One of ordinary skill in the art can understand and implement it without inventive effort.
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 necessary general hardware platform, and certainly can also be implemented by hardware. With this understanding in mind, the above-described technical solutions may be embodied in the form of a software product, which can 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, etc.) to execute the methods described in the embodiments or some parts of the embodiments.
Finally, it should be noted that: the above examples are only intended to illustrate the technical solutions of the present disclosure, not to limit them; although the present disclosure has been described in detail with reference to the foregoing embodiments, it should 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 such modifications or substitutions do not depart from the spirit and scope of the corresponding technical solutions of the embodiments of the present disclosure.
Claims (10)
1. A method for generating an electronic medical record is characterized by comprising the following steps:
acquiring a medical record template corresponding to a department attribute of a user identifier, wherein the medical record template comprises element components and preset medical record description data corresponding to the element components;
acquiring patient medical record data generated based on the element component and the preset medical record description data;
verifying the accuracy of the patient medical record data;
in a case that the patient medical record data is determined to be accurate, an electronic medical record is generated based on the patient medical record data.
2. The method for generating an electronic medical record according to claim 1, wherein the patient medical record data comprises: the filled element components and the medical record description data corresponding to the filled element components;
the verifying the accuracy of the patient medical record data comprises:
acquiring the filled-in element components in the patient medical record data;
judging whether medical record description data corresponding to the filled element assembly carrying the necessary filling mark is empty or not to obtain a judgment result;
and under the condition that the filled element components are determined to be consistent with the element components and the judgment result is not null, determining that the patient medical record data is accurate.
3. The method for generating an electronic medical record according to claim 2, wherein the verifying the accuracy of the patient medical record data comprises:
acquiring preset incidence relation among the element assemblies;
identifying the legality of the medical record description data based on the incidence relation;
and determining that the patient medical record data is accurate under the condition that the medical record description data is determined to be legal.
4. The method for generating an electronic medical record according to any one of claims 1-3, wherein the obtaining of the medical record template corresponding to the department attribute of the user identifier comprises:
acquiring a template identifier corresponding to the department attribute of the user identifier;
acquiring an initial medical record template corresponding to the template identifier;
acquiring the information of the patient at the current moment;
and loading the visit information into the initial medical record template to obtain a medical record template corresponding to the patient.
5. The method for generating an electronic medical record according to any one of claims 1-3, wherein the acquiring patient medical record data generated based on the element component and the preset medical record description data comprises:
and acquiring patient medical record data obtained by modifying the preset medical record description data corresponding to the element assembly.
6. The method for generating an electronic medical record according to any one of claims 1-3, further comprising, after generating the electronic medical record:
acquiring target patient medical record data corresponding to a target filled element assembly corresponding to at least one patient;
determining a new diagnostic plan for the patient based on the target patient medical record data.
7. An apparatus for generating an electronic medical record, comprising:
the medical record system comprises a first acquisition module, a second acquisition module and a third acquisition module, wherein the first acquisition module is used for acquiring a medical record template corresponding to the department attribute of a user identifier, and the medical record template comprises element components and preset medical record description data corresponding to the element components;
the second acquisition module is used for acquiring patient medical record data generated based on the element assembly and the preset medical record description data;
the verification module is used for verifying the accuracy of the patient medical record data;
and the generating module is used for generating the electronic medical record based on the patient medical record data under the condition that the patient medical record data is determined to be accurate.
8. An electronic device comprising a memory, a processor and a computer program stored on the memory and executable on the processor, wherein the processor implements the method for generating an electronic medical record according to any one of claims 1 to 6 when executing the program.
9. A non-transitory computer-readable storage medium having a computer program stored thereon, wherein the computer program, when executed by a processor, implements the method for generating an electronic medical record according to any one of claims 1 to 6.
10. A computer program product comprising a computer program, wherein the computer program, when executed by a processor, implements the method for generating an electronic medical record according to any of claims 1 to 6.
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