CN116895357A - Electronic medical record generation method, device, equipment and medium - Google Patents
Electronic medical record generation method, device, equipment and medium Download PDFInfo
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Abstract
The application relates to the field of artificial intelligence and medical health, and discloses a method, a device, electronic equipment and a storage medium for generating an electronic medical record, wherein the medical record can be automatically filled after an inquiry process, and the method comprises the following steps: constructing a consultation template according to the clinical diagnosis path data; performing medical record link marking on each node in the inquiry template to obtain a link mark; acquiring the complaint information and the basic information of a patient, and selecting a questioning path of the questioning template according to the complaint information and the basic information; according to the questioning path and the questioning template, the patient is subjected to questioning to obtain a patient questioning and answering board; when the information in the patient inquiry and response board is incomplete, carrying out manual inquiry on the patient to obtain patient supplementary information; and generating medical records of the patient inquiry response plate and the patient supplementary information according to the link marks to obtain the electronic medical records of the patient. The application can improve the accuracy and the generation efficiency of the electronic medical record.
Description
Technical Field
The present application relates to the field of artificial intelligence and medical health, and in particular, to a method and apparatus for generating an electronic medical record, an electronic device, and a readable storage medium.
Background
Medical history refers to the record of the course of a medical activity, such as examination, diagnosis, treatment, etc., performed by a doctor on a patient. The medical records are not only summary of clinical practice work, but also legal basis for exploring disease rules and treating medical disputes. The medical record has important effects on medical treatment, prevention, teaching, scientific research, hospital management and the like.
There are two methods for generating medical records that are common at present: firstly, after the inquiry is finished, a doctor fills in according to the dialogue between doctors and patients, and the method has slower medical record generation efficiency, and memory errors or omission easily occur, so that medical record filling errors are caused; the second is to use entity recognition model to extract the features of symptoms, diseases, duration and the like from the dialogue data, then classify the extracted features into the necessary filling of electronic medical records such as current medical history, allergy history, medication history and the like.
Disclosure of Invention
The application provides a method, a device, electronic equipment and a readable storage medium for generating an electronic medical record, which effectively improve the convenience and accuracy of financial text classification and aim at improving the accuracy and the generation efficiency of the electronic medical record and reducing the working pressure of doctors.
In order to achieve the above object, the present application provides a method for generating an electronic medical record, the method comprising:
acquiring clinical diagnosis path data, and constructing a consultation template according to the clinical diagnosis path data;
performing medical record link marking on each node in the inquiry template to obtain a link mark;
acquiring the complaint information and the basic information of a patient, and selecting a questioning path of the questioning template according to the complaint information and the basic information;
according to the questioning path and the questioning template, the patient is subjected to questioning to obtain a patient questioning and answering board;
when the information in the patient inquiry and response board is incomplete, carrying out manual inquiry on the patient to obtain patient supplementary information;
and generating medical records of the patient inquiry response plate and the patient supplementary information according to the link marks to obtain the electronic medical records of the patient.
Optionally, the generating medical records of the patient inquiry and answer board and the patient supplementary information according to the link mark to obtain an electronic medical record of the patient includes:
constructing an electronic medical record template;
filling a patient inquiry board of each node into the electronic medical record template according to the link mark of each node in the inquiry template to obtain an initial electronic medical record;
performing text classification on the patient supplementary information by using a preset text classification model to obtain the text type of the patient supplementary information;
and filling the patient supplementary information into the initial electronic medical record according to the text type to obtain the electronic medical record of the patient.
Optionally, the constructing a consultation template according to the clinical diagnosis path data includes:
crawling medical knowledge of a preset disease by using a preset web crawler;
generating a question to be asked of the preset disease according to the clinical diagnosis path data and the medical knowledge of the preset disease;
and sequencing and layering the questions to be questioned according to the order of the clinical diagnosis path data to obtain a questioning template.
Optionally, the step of performing medical record link marking on each node in the inquiry template to obtain a link mark includes:
acquiring marked nodes of a completed inquiry template, and extracting link mark training data, node problem text training data and node problem option training data in the marked nodes of the completed inquiry template;
training a preset link classification model according to the link marking training data, the node problem text training data and the node problem option training data to obtain a trained link classification model;
performing link classification on untagged inquiry template nodes by using the trained link classification model to obtain link types;
and performing link marking on the untagged inquiry template nodes according to the link type to obtain link marks.
Optionally, the selecting a question path of the question template according to the complaint information and the basic information includes:
extracting symptom keywords related to symptoms in the complaint information;
analyzing the symptom keywords, inquiring a preset medical knowledge graph, and determining the names of diseases possibly suffered by the patient;
according to the disease name, carrying out primary inquiry template path screening on the inquiry template to obtain an initial inquiry path;
and screening the path of the secondary inquiry template for the primary inquiry path according to the basic information to obtain the inquiry path of the inquiry template corresponding to the patient.
Alternatively, the process may be carried out in a single-stage,
and according to the questioning path and the questioning template, performing a questioning on the patient to obtain a patient questioning and answering board, wherein the questioning and answering board comprises:
according to the questioning path and the questioning template, questioning and questioning are carried out on the patient, and questioning answers of the patient are obtained;
judging whether the inquiry answers meet the precondition of the next question in the inquiry path;
if the inquiry response meets the precondition of the next question in the inquiry path, returning to the step of inquiring the patient according to the inquiry path and the inquiry template until the inquiry template confirms the disease information of the patient, and stopping inquiry;
if the inquiry answer does not accord with the precondition of the next question in the inquiry path, generating a new inquiry path according to the inquiry answer, and returning to the step of inquiring the patient according to the inquiry path and the inquiry template until the inquiry template confirms the disease information of the patient, and stopping inquiry;
and sorting and storing the inquiry answers of the patient to obtain a patient inquiry answer template.
In order to solve the above problems, the present application further provides an electronic medical record generating device, including:
the inquiry template construction module is used for acquiring clinical diagnosis path data, constructing an inquiry template according to the clinical diagnosis path data, marking each node in the inquiry template in a medical record link to obtain a link mark, acquiring main complaint information and basic information of a patient, and selecting an inquiry path of the inquiry template according to the main complaint information and the basic information;
the patient inquiry module is used for carrying out inquiry on the patient according to the inquiry path and the inquiry template to obtain a patient inquiry answering board, and carrying out manual inquiry on the patient when the information in the patient inquiry answering board is incomplete to obtain patient supplementary information;
and the electronic medical record generating module is used for generating medical records of the patient inquiry and answer board and the patient supplementary information according to the link marks to obtain the electronic medical record of the patient.
In order to solve the above-mentioned problems, the present application also provides an electronic apparatus including:
a memory storing at least one computer program; and
And the processor executes the computer program stored in the memory to realize the electronic medical record generation method.
In order to solve the above-mentioned problems, the present application also provides a computer-readable storage medium having stored therein at least one computer program that is executed by a processor in an electronic device to implement the above-mentioned electronic medical record generating method.
According to the embodiment of the application, a query template is constructed according to the clinical diagnosis path data, medical record links are marked on each node in the query template to obtain link marks, the uncertainty and error probability of a model for predicting which link of medical records to which doctor-patient dialogue data belongs are reduced, the accuracy of the electronic medical record is improved, furthermore, the complaint information and the basic information of a patient are obtained, the diagnosis path of the query template is selected according to the complaint information and the basic information, and the patient is queried according to the query path and the query template to obtain a patient query plate, so that the time of doctor query flow is shortened, and the efficiency of generating the electronic medical record is improved. Therefore, the method, the device, the equipment and the storage medium for generating the electronic medical record can improve the accuracy and the generating efficiency of the electronic medical record and reduce the working pressure of doctors.
Drawings
FIG. 1 is a flowchart of a method for generating an electronic medical record according to an embodiment of the present application;
FIGS. 2 and 3 are flowcharts illustrating a detailed implementation of one of the steps in the electronic medical record generating method according to an embodiment of the present application;
FIG. 4 is a schematic block diagram of an electronic medical record generating device according to an embodiment of the present application;
fig. 5 is a schematic diagram of an internal structure of an electronic device for implementing a method for generating an electronic medical record according to an embodiment of the present application;
the achievement of the objects, functional features and advantages of the present application will be further described with reference to the accompanying drawings, in conjunction with the embodiments.
Detailed Description
It should be understood that the specific embodiments described herein are for purposes of illustration only and are not intended to limit the scope of the application.
The embodiment of the application provides a method for generating an electronic medical record. The execution main body of the electronic medical record generating method comprises at least one of a server, a terminal and the like which can be configured to execute the method provided by the embodiment of the application. In other words, the electronic medical record generating method may be performed by software or hardware installed in a terminal device or a server device, and the software may be a blockchain platform. The server may include an independent server, and may also include a cloud server that provides cloud services, cloud databases, cloud computing, cloud functions, cloud storage, network services, cloud communications, middleware services, domain name services, security services, content delivery networks (Content Delivery Network, CDN), and basic cloud computing services such as big data and artificial intelligence platforms.
Referring to fig. 1, a flowchart of a method for generating an electronic medical record according to an embodiment of the present application is shown, where in the embodiment of the present application, the method includes:
s1, acquiring clinical diagnosis path data, and constructing a consultation template according to the clinical diagnosis path data.
In the embodiment of the application, the clinical diagnosis path data can be a standardized set of treatment modes and treatment programs established for various diseases provided by authorities and used for standardizing medical behaviors.
In an alternative embodiment of the present application, clinical diagnosis path data corresponding to various diseases may be obtained through a official network query, for example, an official website of the national health committee and an official website of the hospital.
Further, after the clinical diagnosis path data is acquired, it is also necessary to determine whether the acquired clinical diagnosis path data is the latest version in order to ensure the validity of the data.
According to the embodiment of the application, the inquiry template is constructed according to the clinical diagnosis path data, so that the dialogue flow between doctors and patients based on the inquiry template is realized, the working pressure of doctors is reduced, and the working efficiency of inquiry work is improved.
In detail, as an alternative embodiment of the present application, referring to fig. 2, the constructing a consultation template according to the clinical diagnosis path data includes:
s11, crawling medical knowledge of a preset disease by using a preset web crawler;
s12, generating a question to be asked of the preset disease according to the clinical diagnosis path data and the medical knowledge of the preset disease;
s13, sorting and layering the questions to be asked according to the order of the clinical diagnosis path data to obtain a consultation template.
In the embodiment of the application, the medical knowledge can be knowledge data of common symptoms, signs, examination items, diagnosis standards and other aspects of diseases.
In an alternative embodiment of the present application, various questions about the disease, such as the patient's symptoms, medical history, family history, lifestyle, etc., are determined based on official clinical diagnosis routes and knowledge data of the common symptoms, signs, examination items, diagnosis criteria, etc., of the disease.
Further, in another alternative embodiment of the application, the questions to be asked are organized according to the logic sequence according to the official clinical diagnosis path, so that the hierarchical cleaning of the questions is ensured, and the doctor can know the patient deeply, thereby reducing the time of doctor's consultation and improving the efficiency of doctor's consultation.
It should be noted that, the construction of the inquiry template is a very complex process, so that the embodiment of the application also needs manual participation of doctors, clinical specialists and technicians when constructing the inquiry template, and further, after the construction of the inquiry template is completed, the inquiry template needs to be adjusted according to feedback in practical application, so that the accuracy and the inquiry efficiency of the inquiry template are improved.
S2, performing medical record link marking on each node in the inquiry template to obtain a link mark.
In the embodiment of the application, each node in the inquiry template comprises a question content area, a patient answer area, a medical record link and other areas. The link mark comprises a link name and a link type, for example, the node name of a certain node of the inquiry template is a medical history before pregnancy, and the link mark of the node is provided with the link name: medical history collection, link type: history of past disease.
According to the embodiment of the application, the medical record links are marked on each node in the inquiry template to obtain the link marks so as to classify the inquiry questions and the patient answers in each node, so that the method and the device can be used for quickly marking the electronic medical record, the time for generating the electronic medical record is shortened, and the efficiency for generating the electronic medical record is improved.
In an alternative embodiment of the application, each node in the inquiry template can be labeled in a manual labeling mode, but the method is too labor-consuming and has low speed, so that each node in the inquiry template can be labeled in a medical record link by using a deep learning text classification algorithm to obtain a link label.
In detail, as an optional embodiment of the present application, referring to fig. 3, the step of performing medical record link marking on each node in the query template to obtain a link mark includes:
s21, acquiring marked nodes of the completed inquiry templates, and extracting link mark training data, node problem text training data and node problem option training data in the nodes of the completed inquiry templates;
s22, training a preset link classification model according to the link marking training data, the node problem text training data and the node problem option training data to obtain a trained link classification model;
s23, performing link classification on untagged inquiry template nodes by using the trained link classification model to obtain link types;
s24, performing link marking on the untagged inquiry template nodes according to the link type to obtain link marks.
In the embodiment of the application, the preset link classification model may be a text classification model based on deep learning, wherein the text classification model includes deep learning models such as a convolutional neural network and a cyclic neural network.
In the embodiment of the application, when the number of the nodes in the inquiry template is excessive, intelligent link marking of the nodes of the inquiry template can be realized by training the text classification model, so that the labor consumption is reduced.
However, in order to ensure the accuracy of link labeling, when the number of nodes in the inquiry template is not large, the link labeling is performed manually in the embodiment of the application.
S3, acquiring the complaint information and the basic information of the patient, and selecting a questioning path of the questioning template according to the complaint information and the basic information.
In the embodiment of the application, the complaint information can be the self-help symptoms or (and) signs, properties and duration of the patient. The basic information includes information such as the age, sex, name, etc. of the patient. The question path refers to a question sequence selected by a question template according to information of a patient.
In an alternative embodiment of the application, the patient can be required to fill in basic information and main complaint information in the pre-consultation, and the main complaint information and the basic information are stored in a preset patient database according to the filled main complaint information and the basic information of the patient, so that the main complaint information and the basic information of the patient can be called by reading the data in the patient database in the consultation stage, and the problem that the consultation team is blocked and the consultation time is prolonged due to the fact that the patient fills in the main complaint information when the consultation occurs is avoided.
Further, according to the embodiment of the application, the diagnosis path of the inquiry template is selected according to the complaint message and the basic information so as to generate the duration of the illness, and the illness information of the patient can be more comprehensively covered, thereby ensuring the accuracy and the comprehensiveness of the electronic medical record.
In detail, as an optional embodiment of the present application, the selecting the question path of the question template according to the complaint information and the basic information includes:
extracting symptom keywords related to symptoms in the complaint information;
analyzing the symptom keywords, inquiring a preset medical knowledge graph, and determining the names of diseases possibly suffered by the patient;
according to the disease name, carrying out primary inquiry template path screening on the inquiry template to obtain an initial inquiry path;
and screening the path of the secondary inquiry template for the primary inquiry path according to the basic information to obtain the inquiry path of the inquiry template corresponding to the patient.
In the embodiment of the application, the symptom keywords can be keywords for describing physical discomfort, such as words of headache, nausea, vomiting and the like. The preset medical knowledge graph can be a medical knowledge graph of the corresponding relation between symptoms and diseases, and is used for confirming the types of the diseases according to the symptoms.
Because some symptoms may have different reasons and processing methods in patients of different sexes or ages, after obtaining an initial questioning path, the embodiment of the application also needs to perform secondary questioning template path screening on the initial questioning path according to the basic information to obtain a questioning path of the questioning template corresponding to the patient.
S4, carrying out inquiry on the patient according to the inquiry path and the inquiry template to obtain a patient inquiry response board.
In the embodiment of the application, the patient inquiry and answer board can be a board for providing the patient with the question answer by each node in the inquiry and answer board.
Because the composition of the electronic medical record contains a series of information such as patient medical history, in the embodiment of the application, before the electronic medical record is generated, the inquiry answers of the patient are required to be collected and stored, and furthermore, in order to facilitate collection and storage of the inquiry answers of the patient, a module for filling out the inquiry answers of the patient can be provided in the inquiry template, so that the construction of the inquiry answer board of the patient is realized.
Further, as an optional embodiment of the present application, the performing a query on the patient according to the query path and the query template to obtain a patient query board includes:
according to the questioning path and the questioning template, questioning and questioning are carried out on the patient, and questioning answers of the patient are obtained;
judging whether the inquiry answers meet the precondition of the next question in the inquiry path;
if the inquiry response meets the precondition of the next question in the inquiry path, returning to the step of inquiring the patient according to the inquiry path and the inquiry template until the inquiry template confirms the disease information of the patient, and stopping inquiry;
if the inquiry answer does not accord with the precondition of the next question in the inquiry path, generating a new inquiry path according to the inquiry answer, and returning to the step of inquiring the patient according to the inquiry path and the inquiry template until the inquiry template confirms the disease information of the patient, and stopping inquiry;
and sorting and storing the inquiry answers of the patient to obtain a patient inquiry answer template.
In the embodiment of the present application, the precondition may be a precondition that the medical staff sets each problem trigger according to medical knowledge.
In an alternative embodiment of the application, in order to ensure the accuracy of the obtained patient question-answering template, when the question answer does not meet the precondition of the next question in the question path, a new question path needs to be regenerated according to the answer information and the complaint information of the patient, thereby improving the accuracy of the electronic medical record.
S5, when the information in the patient inquiry and response board is incomplete, carrying out manual inquiry on the patient to obtain patient supplementary information.
Because the patient inquiry and answer board fills out for the patient himself, the information omission and other things possibly occur, so that the diagnosis is wrong and the electronic medical record is generated wrong, in the alternative embodiment of the application, a doctor is required to check the patient inquiry and answer board to judge whether the information in the patient inquiry and answer board is complete, and when the information in the patient inquiry and answer board is incomplete, the patient is manually inquired, so that the supplementary information of the patient is obtained.
Further, in an alternative embodiment of the application, when the information in the patient inquiry and answering plate is incomplete, a doctor performs inquiry on the patient according to own medical knowledge, so that the inquiry and missing repair of the inquiry and answering plate is realized, the integrity of the patient inquiry and answering plate is ensured, and the accuracy of the electronic medical record is improved.
S6, according to the link marks, medical record generation is carried out on the patient inquiry response plate and the patient supplementary information, and the electronic medical record of the patient is obtained. In an alternative embodiment of the present application, the electronic medical record module corresponding to the text information answered by each patient in the patient inquiry and answer board is confirmed by the link label of each node in the patient inquiry and answer board, for example, when the link type in the link label of a certain node is the past disease history, the text information answered by the patient of the node can be filled into the past history template in the electronic medical record.
In detail, as an optional embodiment of the present application, the generating medical records of the patient inquiry and response board and the patient supplementary information according to the link mark to obtain an electronic medical record of the patient includes:
constructing an electronic medical record template;
filling a patient inquiry board of each node into the electronic medical record template according to the link mark of each node in the inquiry template to obtain an initial electronic medical record;
performing text classification on the patient supplementary information by using a preset text classification model to obtain the text type of the patient supplementary information;
and filling the patient supplementary information into the initial electronic medical record according to the text type to obtain the electronic medical record of the patient.
In the embodiment of the application, the preset text classification model can be a text classification model trained by using a large amount of patient inquiry data, and is mainly used for classifying latitude of the patient inquiry data, wherein the latitude classification comprises latitude such as current medical history, past history, medication history, allergy history, family history, personal history and the like.
In an alternative embodiment of the application, the patient inquiry answering board and the patient supplementary information in the inquiry template are filled in the constructed electronic medical record template in a filling mode, so that the electronic medical record of the patient is generated, the process of inputting the patient inquiry information manually by a doctor is reduced, and the efficiency of generating the electronic medical record is improved.
According to the embodiment of the application, a query template is constructed according to the clinical diagnosis path data, medical record links are marked on each node in the query template to obtain link marks, the uncertainty and error probability of a model for predicting which link of medical records to which doctor-patient dialogue data belongs are reduced, the accuracy of the electronic medical record is improved, furthermore, the complaint information and the basic information of a patient are obtained, the diagnosis path of the query template is selected according to the complaint information and the basic information, and the patient is queried according to the query path and the query template to obtain a patient query plate, so that the time of doctor query flow is shortened, and the efficiency of generating the electronic medical record is improved. Therefore, the method for generating the electronic medical record can improve the accuracy and the generating efficiency of the electronic medical record and reduce the working pressure of doctors.
As shown in fig. 4, a functional block diagram of the electronic medical record generating device according to the present application is shown.
The electronic medical record generating device 100 of the present application may be installed in an electronic apparatus. Depending on the functions implemented, the electronic medical record generating apparatus 100 may include a query template building module 101, a patient query module 102, and an electronic medical record generating module 103, which may also be referred to as a unit, which refers to a series of computer program segments that can be executed by a processor of an electronic device and that can perform a fixed function, and are stored in a memory of the electronic device.
In the present embodiment, the functions concerning the respective modules/units are as follows:
the inquiry template construction module 101 is configured to obtain clinical diagnosis path data, construct an inquiry template according to the clinical diagnosis path data, perform medical record link marking on each node in the inquiry template, obtain a link mark, obtain main complaint information and basic information of a patient, and select an inquiry path of the inquiry template according to the main complaint information and the basic information.
The patient inquiry module 102 is configured to perform inquiry on the patient according to the inquiry path and the inquiry template to obtain a patient inquiry board, and perform manual inquiry on the patient when information in the patient inquiry board is incomplete to obtain patient supplementary information.
The electronic medical record generating module 103 is configured to generate medical records of the patient inquiry and response board and the patient supplementary information according to the link mark, so as to obtain an electronic medical record of the patient.
According to the embodiment of the application, a query template is constructed according to the clinical diagnosis path data, medical record links are marked on each node in the query template to obtain link marks, the uncertainty and error probability of a model for predicting which link of medical records to which doctor-patient dialogue data belongs are reduced, the accuracy of the electronic medical record is improved, furthermore, the complaint information and the basic information of a patient are obtained, the diagnosis path of the query template is selected according to the complaint information and the basic information, and the patient is queried according to the query path and the query template to obtain a patient query plate, so that the time of doctor query flow is shortened, and the efficiency of generating the electronic medical record is improved. Therefore, the electronic medical record generating device provided by the application can improve the accuracy and the generating efficiency of the electronic medical record and reduce the working pressure of doctors.
Fig. 5 is a schematic structural diagram of an electronic device for implementing the electronic medical record generating method according to the present application.
The electronic device may comprise a processor 10, a memory 11, a communication bus 12 and a communication interface 13, and may further comprise a computer program, such as an electronic medical record generating program, stored in the memory 11 and executable on the processor 10.
The memory 11 includes at least one type of readable storage medium, including flash memory, a mobile hard disk, a multimedia card, a card memory (e.g., SD or DX memory, etc.), a magnetic memory, a magnetic disk, an optical disk, etc. The memory 11 may in some embodiments be an internal storage unit of the electronic device, such as a mobile hard disk of the electronic device. The memory 11 may in other embodiments also be an external storage device of the electronic device, such as a plug-in mobile hard disk, a Smart Media Card (SMC), a Secure Digital (SD) Card, a Flash memory Card (Flash Card) or the like, which are provided on the electronic device. Further, the memory 11 may also include both an internal storage unit and an external storage device of the electronic device. The memory 11 may be used not only for storing application software installed in an electronic device and various data, such as codes of electronic medical record generation programs, but also for temporarily storing data that has been output or is to be output.
The processor 10 may be comprised of integrated circuits in some embodiments, for example, a single packaged integrated circuit, or may be comprised of multiple integrated circuits packaged with the same or different functions, including one or more central processing units (Central Processing Unit, CPU), microprocessors, digital processing chips, graphics processors, combinations of various control chips, and the like. The processor 10 is a Control Unit (Control Unit) of the electronic device, connects various components of the entire electronic device using various interfaces and lines, and executes various functions of the electronic device and processes data by running or executing programs or modules (e.g., electronic medical record generation programs, etc.) stored in the memory 11, and calling data stored in the memory 11.
The communication bus 12 may be a peripheral component interconnect standard (PerIPheral Component Interconnect, PCI) bus, or an extended industry standard architecture (Extended Industry Standard Architecture, EISA) bus, among others. The bus may be classified as an address bus, a data bus, a control bus, etc. The communication bus 12 is arranged to enable a connection communication between the memory 11 and at least one processor 10 etc. For ease of illustration, the figures are shown with only one bold line, but not with only one bus or one type of bus.
Fig. 5 shows only an electronic device with components, and it will be understood by those skilled in the art that the structure shown in fig. 5 is not limiting of the electronic device and may include fewer or more components than shown, or may combine certain components, or a different arrangement of components.
For example, although not shown, the electronic device may further include a power source (such as a battery) for supplying power to the respective components, and preferably, the power source may be logically connected to the at least one processor 10 through a power management device, so that functions of charge management, discharge management, power consumption management, and the like are implemented through the power management device. The power supply may also include one or more of any of a direct current or alternating current power supply, recharging device, power failure detection circuit, power converter or inverter, power status indicator, etc. The electronic device may further include various sensors, bluetooth modules, wi-Fi modules, etc., which are not described herein.
Optionally, the communication interface 13 may comprise a wired interface and/or a wireless interface (e.g., WI-FI interface, bluetooth interface, etc.), typically used to establish a communication connection between the electronic device and other electronic devices.
Optionally, the communication interface 13 may further comprise a user interface, which may be a Display, an input unit, such as a Keyboard (Keyboard), or a standard wired interface, a wireless interface. Alternatively, in some embodiments, the display may be an LED display, a liquid crystal display, a touch-sensitive liquid crystal display, an OLED (Organic Light-Emitting Diode) touch, or the like. The display may also be referred to as a display screen or display unit, as appropriate, for displaying information processed in the electronic device and for displaying a visual user interface.
It should be understood that the embodiments described are for illustrative purposes only and are not limited to this configuration in the scope of the patent application.
The electronic medical record generating program stored in the memory 11 of the electronic device is a combination of a plurality of computer programs, which when run in the processor 10, can implement:
acquiring clinical diagnosis path data, and constructing a consultation template according to the clinical diagnosis path data;
performing medical record link marking on each node in the inquiry template to obtain a link mark;
acquiring the complaint information and the basic information of a patient, and selecting a questioning path of the questioning template according to the complaint information and the basic information;
according to the questioning path and the questioning template, the patient is subjected to questioning to obtain a patient questioning and answering board;
when the information in the patient inquiry and response board is incomplete, carrying out manual inquiry on the patient to obtain patient supplementary information;
and generating medical records of the patient inquiry response plate and the patient supplementary information according to the link marks to obtain the electronic medical records of the patient.
In particular, the specific implementation method of the processor 10 on the computer program may refer to the description of the relevant steps in the corresponding embodiment of fig. 1, which is not repeated herein.
Further, the electronic device integrated modules/units, if implemented in the form of software functional units and sold or used as stand-alone products, may be stored in a computer readable storage medium. The computer readable medium may be non-volatile or volatile. The computer readable medium may include: any entity or device capable of carrying the computer program code, a recording medium, a U disk, a removable hard disk, a magnetic disk, an optical disk, a computer Memory, a Read-Only Memory (ROM).
Embodiments of the present application may also provide a computer readable storage medium storing a computer program which, when executed by a processor of an electronic device, may implement:
acquiring clinical diagnosis path data, and constructing a consultation template according to the clinical diagnosis path data;
performing medical record link marking on each node in the inquiry template to obtain a link mark;
acquiring the complaint information and the basic information of a patient, and selecting a questioning path of the questioning template according to the complaint information and the basic information;
according to the questioning path and the questioning template, the patient is subjected to questioning to obtain a patient questioning and answering board;
when the information in the patient inquiry and response board is incomplete, carrying out manual inquiry on the patient to obtain patient supplementary information;
and generating medical records of the patient inquiry response plate and the patient supplementary information according to the link marks to obtain the electronic medical records of the patient.
Further, the computer-usable storage medium may mainly include a storage program area and a storage data area, wherein the storage program area may store an operating system, an application program required for at least one function, and the like; the storage data area may store data created from the use of blockchain nodes, and the like.
In the embodiments provided in the present application, it should be understood that the disclosed electronic device, apparatus and method may be implemented in other manners. For example, the above-described apparatus embodiments are merely illustrative, and for example, the division of the modules is merely a logical function division, and there may be other manners of division when actually implemented.
The modules described as separate components may or may not be physically separate, and components shown as modules may or may not be physical units, may be located in one place, or may be distributed over multiple network units. Some or all of the modules may be selected according to actual needs to achieve the purpose of the solution of this embodiment.
In addition, each functional module in the embodiments of the present application may be integrated in one processing unit, or each unit may exist alone physically, or two or more units may be integrated in one unit. The integrated units can be realized in a form of hardware or a form of hardware and a form of software functional modules.
It will be evident to those skilled in the art that the application is not limited to the details of the foregoing illustrative embodiments, and that the present application may be embodied in other specific forms without departing from the spirit or essential characteristics thereof.
The present embodiments are, therefore, to be considered in all respects as illustrative and not restrictive, the scope of the application being indicated by the appended claims rather than by the foregoing description, and all changes which come within the meaning and range of equivalency of the claims are therefore intended to be embraced therein. Any reference signs in the claims shall not be construed as limiting the claim concerned.
The blockchain is a novel application mode of computer technologies such as distributed data storage, point-to-point transmission, consensus mechanism, encryption algorithm and the like. The Blockchain (Blockchain), which is essentially a decentralised database, is a string of data blocks that are generated by cryptographic means in association, each data block containing a batch of information of network transactions for verifying the validity of the information (anti-counterfeiting) and generating the next block. The blockchain may include a blockchain underlying platform, a platform product services layer, an application services layer, and the like.
Furthermore, it is evident that the word "comprising" does not exclude other elements or steps, and that the singular does not exclude a plurality. A plurality of units or means recited in the system claims can also be implemented by means of software or hardware by means of one unit or means. The terms second, etc. are used to denote a name, but not any particular order.
Finally, it should be noted that the above-mentioned embodiments are merely for illustrating the technical solution of the present application and not for limiting the same, and although the present application has been described in detail with reference to the preferred embodiments, it should be understood by those skilled in the art that modifications and equivalents may be made to the technical solution of the present application without departing from the spirit and scope of the technical solution of the present application.
Claims (10)
1. A method for generating an electronic medical record, the method comprising:
acquiring clinical diagnosis path data, and constructing a consultation template according to the clinical diagnosis path data;
performing medical record link marking on each node in the inquiry template to obtain a link mark;
acquiring the complaint information and the basic information of a patient, and selecting a questioning path of the questioning template according to the complaint information and the basic information;
according to the questioning path and the questioning template, the patient is subjected to questioning to obtain a patient questioning and answering board;
when the information in the patient inquiry and response board is incomplete, carrying out manual inquiry on the patient to obtain patient supplementary information;
and generating medical records of the patient inquiry response plate and the patient supplementary information according to the link marks to obtain the electronic medical records of the patient.
2. The method for generating an electronic medical record according to claim 1, wherein generating the medical record of the patient inquiry and response board and the patient supplementary information according to the link mark to obtain the electronic medical record of the patient comprises:
constructing an electronic medical record template;
filling a patient inquiry board of each node into the electronic medical record template according to the link mark of each node in the inquiry template to obtain an initial electronic medical record;
performing text classification on the patient supplementary information by using a preset text classification model to obtain the text type of the patient supplementary information;
and filling the patient supplementary information into the initial electronic medical record according to the text type to obtain the electronic medical record of the patient.
3. The electronic medical record generation method of claim 1, wherein the constructing a consultation template from the clinical diagnostic path data comprises:
crawling medical knowledge of a preset disease by using a preset web crawler;
generating a question to be asked of the preset disease according to the clinical diagnosis path data and the medical knowledge of the preset disease;
and sequencing and layering the questions to be questioned according to the order of the clinical diagnosis path data to obtain a questioning template.
4. The method for generating an electronic medical record according to claim 1, wherein the step of performing medical record link marking on each node in the inquiry template to obtain a link mark comprises the steps of:
acquiring marked nodes of a completed inquiry template, and extracting link mark training data, node problem text training data and node problem option training data in the marked nodes of the completed inquiry template;
training a preset link classification model according to the link marking training data, the node problem text training data and the node problem option training data to obtain a trained link classification model;
performing link classification on untagged inquiry template nodes by using the trained link classification model to obtain link types;
and performing link marking on the untagged inquiry template nodes according to the link type to obtain link marks.
5. The electronic medical record generating method as set forth in claim 1, wherein the selecting a question path of the question template according to the complaint information and the basic information includes:
extracting symptom keywords related to symptoms in the complaint information;
analyzing the symptom keywords, inquiring a preset medical knowledge graph, and determining the names of diseases possibly suffered by the patient;
according to the disease name, carrying out primary inquiry template path screening on the inquiry template to obtain an initial inquiry path;
and screening the path of the secondary inquiry template for the primary inquiry path according to the basic information to obtain the inquiry path of the inquiry template corresponding to the patient.
6. The electronic medical record generating method according to claim 1, wherein the step of performing a consultation on the patient according to the question path and the consultation template to obtain a patient consultation board comprises the steps of:
according to the questioning path and the questioning template, questioning and questioning are carried out on the patient, and questioning answers of the patient are obtained;
judging whether the inquiry answers meet the precondition of the next question in the inquiry path;
if the inquiry response meets the precondition of the next question in the inquiry path, returning to the step of inquiring the patient according to the inquiry path and the inquiry template until the inquiry template confirms the disease information of the patient, and stopping inquiry;
if the inquiry answer does not accord with the precondition of the next question in the inquiry path, generating a new inquiry path according to the inquiry answer, and returning to the step of inquiring the patient according to the inquiry path and the inquiry template until the inquiry template confirms the disease information of the patient, and stopping inquiry;
and sorting and storing the inquiry answers of the patient to obtain a patient inquiry answer template.
7. An electronic medical record generating device, characterized in that the device comprises:
the inquiry template construction module is used for acquiring clinical diagnosis path data, constructing an inquiry template according to the clinical diagnosis path data, marking each node in the inquiry template in a medical record link to obtain a link mark, acquiring main complaint information and basic information of a patient, and selecting an inquiry path of the inquiry template according to the main complaint information and the basic information;
the patient inquiry module is used for carrying out inquiry on the patient according to the inquiry path and the inquiry template to obtain a patient inquiry answering board, and carrying out manual inquiry on the patient when the information in the patient inquiry answering board is incomplete to obtain patient supplementary information;
and the electronic medical record generating module is used for generating medical records of the patient inquiry and answer board and the patient supplementary information according to the link marks to obtain the electronic medical record of the patient.
8. The apparatus of claim 7, wherein the generating medical records of the patient inquiry board and the patient supplemental information according to the link flag to obtain the patient electronic medical record comprises:
constructing an electronic medical record template;
filling a patient inquiry board of each node into the electronic medical record template according to the link mark of each node in the inquiry template to obtain an initial electronic medical record;
performing text classification on the patient supplementary information by using a preset text classification model to obtain the text type of the patient supplementary information;
and filling the patient supplementary information into the initial electronic medical record according to the text type to obtain the electronic medical record of the patient.
9. An electronic device, the electronic device comprising:
at least one processor; the method comprises the steps of,
a memory communicatively coupled to the at least one processor; wherein,,
the memory stores computer program instructions executable by the at least one processor to enable the at least one processor to perform the electronic medical record generation method of any one of claims 1 to 7.
10. A computer readable storage medium storing a computer program, wherein the computer program when executed by a processor implements the electronic medical record generation method according to any one of claims 1 to 7.
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| CN117936114A (en) * | 2024-03-13 | 2024-04-26 | 湖北福鑫科创信息技术有限公司 | Electronic medical record intelligent analysis and optimization system based on large language model |
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| CN117936114A (en) * | 2024-03-13 | 2024-04-26 | 湖北福鑫科创信息技术有限公司 | Electronic medical record intelligent analysis and optimization system based on large language model |
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