CN1521682A - Electronic medical record computer-management system and medical record information processing method - Google Patents
Electronic medical record computer-management system and medical record information processing method Download PDFInfo
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- CN1521682A CN1521682A CNA031137369A CN03113736A CN1521682A CN 1521682 A CN1521682 A CN 1521682A CN A031137369 A CNA031137369 A CN A031137369A CN 03113736 A CN03113736 A CN 03113736A CN 1521682 A CN1521682 A CN 1521682A
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Abstract
The invention relates to medical information computer processing method and related application software and hardware, in particular an electronic medical record for recording element and data base linkages and the computer-management system and method, wherein the electronic medical record and computer hardware system comprises a computer terminal workstation, a central server and network, an intelligent sheet format electronic medical record mode of case history recording elements and data base electronic sheets linkage is employed for realizing quick medical record input speed, less internal memory occupation and high accuracy in case history information acquisition and processing.
Description
Affiliated technical field
The present invention relates to a kind of medical information computer processing method and relative application software and hardware, further relate to a kind of electronic health record and computer management system and method that writes down key element and database interlock.
Technical background
(electronic patient/medical record EPR/EMR) is meant that the applying electronic computer technology obtains, stores, handles, transmits and show a kind of medical record management technology of the relevant medical information of patient to electronic health record.Electronic health record and the management system thereof of setting up science are the important development directions that hospital information is built.At present, simple words input and the processing based on plain text TXT, Word or Web file layout generally taked in the computer management of clinical case history.This method information input efficiency is not high, take storage space big, be not easy to medical record information is carried out further quantification treatment and intelligent management ([1] Liu Shangyun, Chen Xu. about the discussion of imputting Chinese characters in the electronic health record. Chinese hospital management magazine, 2001,17:294-295.[2] Xu Guoli, Sun Xufang, Lou Lin waits common problem and solution in the use of " army defends engineering " electronic health record. medical information, 2000,14:848-849.).For the science of further strengthening clinical case history information is collected and management, increase work efficiency, the load that lightens one's labor improves quality of medical care, promotion need be set up new electronic health record and computer management system thereof to data mining (Data Mining) research of a large amount of medical history informations.
Summary of the invention
The objective of the invention is to set up a kind of advanced person's electronic health record and computer management system and medical record information disposal route.This electronic health record is taked the intelligent sheet format electronic health record pattern of a kind of medical history record key element and the interlock of database electrical form, can obviously improve the case history input speed, reduce the committed memory capacity, reduce typing errors in text rate and case history and leak a rate, improve science and accuracy that medical record information is collected and handled.
This electronic health record and computer management system thereof comprise the hardware and software two large divisions.Its hardware system is made up of doctor workstation, endoscopy workstation, pathologic finding workstation, care workstation and central server and network thereof; Software systems comprise the special typing and demonstration forms and corresponding database supervisory routine that utilizes Microsoft Access 2000 software programmings to form.
The advantage of this electronic health record and computer management system thereof is:
(1) described electronic health record and computer management system thereof comprise the hardware and software two large divisions, and its hardware components is made up of terminal workstation, central server and network thereof, can be connected with the institute outer network with the hospital network system.
(2) software section of described electronic health record and computer management system thereof comprises that of utilizing that Microsoft Access 2000 software programmings form integrates case history typing window, five data typing split windows and inquiry, demonstration, printing forms and corresponding database supervisory routine, totally 12 functional modules.
(3) electronic health record of described electronic health record and computer management system thereof is taked the intelligent sheet format electronic health record pattern of a kind of medical history record key element and the interlock of database electrical form.Its basic skills is: the field according to electrical form requires to set up record entry, realizes that the medical history record content element is corresponding one by one with the electrical form field.
(4) the medical history record key element of described electronic health record and computer management system thereof has been carried out standardization, key element processing, and important medical history record key element has been carried out standardization and can have been tabulated simultaneously, selects input for clicking.
(5) described electronic health record and computer management system thereof can be at the different operating station typing clinical medical history data, auxiliary examination data, diagnoses and treatment data and follow up a case by regular visits to data respectively, automatically data is integrated by system.
(6) described electronic health record and computer management system thereof can import SPSS automatically with the typing data, EXCELL software carries out statistical study and processing.
Description of drawings
Below in conjunction with accompanying drawing the preferred embodiment of the present invention is described.
Fig. 1 is the basic composition synoptic diagram of electronic health record computer hardware system according to the preferred embodiment of the invention.
Fig. 2 is the basic framework figure of electronic health record computer software according to the preferred embodiment of the invention
Fig. 3 is the synoptic diagram of electronic health record record key element and Database field interlock method according to the preferred embodiment of the invention.
Fig. 4 is large bowel neoplasm case history integral data typing window figure according to the preferred embodiment of the invention.
Among the figure, 1. central server, 2. server admin computing machine, 3. workstation, 4. computer network circuit and equipment, 5. hospital network system, 6. institute's outer network, 7. sheet format electronic health record homepage, 8. write down the electrical form of key element interlock, 9. record key element input control, 10. key element input field, 11. free input fields.
Embodiment
Fig. 1 is the composition synoptic diagram of electronic health record computer hardware system according to the preferred embodiment of the invention.This electronic health record computer hardware system comprises central server (1), server admin computing machine (2) and four kinds of workstations (5, doctor workstation, endoscopy workstation, pathologic finding workstation, care workstation) and corresponding network circuit and equipment (4) composition.This system can be connected with institute's outer network (6) with hospital network system (5).
Fig. 2 is the basic framework figure of electronic health record computer software according to the preferred embodiment of the invention.These software systems comprise that is integrated a case history typing window, five data typing split windows (case history input and demonstration, endoscopy typing and demonstration, case history are checked typing and demonstration, auxiliary examination report, doctor's advice and nursing information) and data input manager, standard case history show printing, safety management and encryption, net connection and system maintenance, data conversion and analysis and other corresponding database supervisory routines, totally 12 functional modules are formed by Microsoft Access 2000 software programmings.
Fig. 3 is that electronic health record writes down the synoptic diagram of key element and Database field interlock according to the preferred embodiment of the invention.Its method is: at first the medical history record key element has been carried out standardization, key element processing.Preferred embodiment is according to the content of large bowel neoplasm standard case history, in conjunction with the field requirement of electrical form, set up 8 aspects, 220 records key element, comprising: 1. case history homepage (7); 2. RAN; 3. progress note; Auxiliary examinations such as 4. various laboratory examinations and cardiogram, X line, B ultrasonic, CT; 5. endoscopy data: 6. pathologic finding content; 7. doctor's advice and NN, 8. other records, are followed up a case by regular visits to tracking at the statistical classification that comprises treatment and therapeutic evaluation, sets up according to clinical case research needs.Then,, set up the respective electronic form, make the electrical form field corresponding one by one with the medical history record key element according to the content element of medical history record.
The electronic health record record key element of preferred embodiment and the concrete grammar of Database field interlock are: to case history homepage general data, comprise patient's name, sex, age, unit or contact address, pathological number, scope number, admission number and prescription on individual diagnosis hospital, section office, ward and bed label, link by directly setting up respective electronic form and database; Take subitem, segmentation to describe to medical history, sings and symptoms, each record comprises position, disease (performance or dispose) and time three elements, can be expressed as " rectum-polyposis-5 year ", " left side accompany colon-cancer/postoperative-1 year ", " behind colon descendens-adenomatous polyp/electrocision-2 years ", " mucous bloody stool-May "; Preferred embodiment is to description, endoscopic biopsy, therapeutic endoscopy and the endoscopic diagnosis of pathology under the scope, also adopt subitem, segmentation record, its each recorded content comprises diseased region, quantity, size and form, surface, border, quality, have or not due to intestine erosion and ulcer and hemorrhage and record key element such as mucous membrane form on every side.
The electronic health record record format and the input policing of preferred embodiment taked relative modular sheet format case history mode.Its method is: to unified fixing medical history record general data, medical history, sings and symptoms, carry out strict markization and quantification, the progress note project big to subjectivity with time and marking of subject matter, set up free input field (11) simultaneously.This method helps embodying the unitarity and the standardization requirement of case history, reflects personal characteristics simultaneously as far as possible.
Fig. 4 is large bowel neoplasm case history integral data typing window figure according to the preferred embodiment of the invention.Its method is: with the essential record key element establishment of the large bowel neoplasm case history of whole preferred embodiment is a typing window, so that whole medical record information is carried out quick typing and processing, reduce mistake and deviation that artificial individual data input occurs easily, improve science and accuracy that medical record information is collected and handled.
Claims (4)
1. electronic health record computer management system and medical record information disposal route, it is characterized in that, this system comprises the hardware and software two large divisions, its hardware components is made up of multiple workstation (comprising doctor workstation, endoscopy workstation, pathologic finding workstation, care workstation) and central server and network thereof, can be connected with the institute outer network with the hospital network system; Its software section comprises that of utilizing that Microsoft Access 2000 works out integrates case history typing window, five data typing split windows and inquiry, demonstration, printing forms and corresponding database supervisory routine, totally 12 functional modules.
2. electronic health record computer management system according to claim 1 and medical record information disposal route, it is characterized in that, this system takes the sheet format electronic health record pattern of a kind of medical history record key element and the interlock of database electrical form, realizes that the medical history record content element is corresponding one by one with the electrical form field.
3. electronic health record computer management system according to claim 1 and medical record information disposal route, it is characterized in that, the medical history record key element of this electronic health record and computer management system thereof has been carried out standardization, key element processing, important medical history record key element has been carried out standardization and can have been tabulated simultaneously, selects input for clicking.
4. electronic health record computer management system according to claim 1 and medical record information disposal route is characterized in that, this electronic health record record format is taked relative modular sheet format case history mode with input policing.
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| CNA031137369A CN1521682A (en) | 2003-02-10 | 2003-02-10 | Electronic medical record computer-management system and medical record information processing method |
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| CNA031137369A CN1521682A (en) | 2003-02-10 | 2003-02-10 | Electronic medical record computer-management system and medical record information processing method |
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Cited By (12)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN100428754C (en) * | 2004-11-26 | 2008-10-22 | 上海理工大学 | Medical record exchanging system based on ebXML |
| CN101908093A (en) * | 2010-01-25 | 2010-12-08 | 田小平 | Electronic medical record and method and system for controlling medical process on the basis of same |
| CN102651098A (en) * | 2011-02-24 | 2012-08-29 | 悦康健康管理顾问科技股份有限公司 | Online integration system for sickness condition |
| CN102799753A (en) * | 2011-05-27 | 2012-11-28 | 上海中医药大学附属曙光医院 | Method for filtering quiver wave by macroprogram |
| CN102929789A (en) * | 2012-09-21 | 2013-02-13 | 曙光信息产业(北京)有限公司 | Record organizational method and record organizational structure |
| CN104615652A (en) * | 2014-12-29 | 2015-05-13 | 曙光云计算技术有限公司 | Organization method for auxiliary records |
| CN104915573A (en) * | 2015-07-01 | 2015-09-16 | 深圳市申泓科技有限公司 | Disease category processing platform based on smart health care |
| CN105204708A (en) * | 2014-06-11 | 2015-12-30 | 株式会社Pfu | Information processing device and display method |
| CN105550504A (en) * | 2015-12-09 | 2016-05-04 | 高玮 | Mobile medical information system and medical information processing method |
| CN108776750A (en) * | 2018-04-20 | 2018-11-09 | 新疆维吾尔自治区胸科医院 | A kind of Drug-Resistant Mycobacterium tuberculosis base construction method |
| CN109785922A (en) * | 2018-12-14 | 2019-05-21 | 平安万家医疗投资管理有限责任公司 | A kind of method for uploading and system of medical history information |
| CN111524568A (en) * | 2020-04-24 | 2020-08-11 | 常州昊泽信息科技有限公司 | Electronic medical record retrieval system |
-
2003
- 2003-02-10 CN CNA031137369A patent/CN1521682A/en active Pending
Cited By (18)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN100428754C (en) * | 2004-11-26 | 2008-10-22 | 上海理工大学 | Medical record exchanging system based on ebXML |
| CN101908093A (en) * | 2010-01-25 | 2010-12-08 | 田小平 | Electronic medical record and method and system for controlling medical process on the basis of same |
| CN102651098B (en) * | 2011-02-24 | 2016-03-09 | 悦康健康管理顾问科技股份有限公司 | The online integration system of the patient's condition |
| CN102651098A (en) * | 2011-02-24 | 2012-08-29 | 悦康健康管理顾问科技股份有限公司 | Online integration system for sickness condition |
| CN102799753A (en) * | 2011-05-27 | 2012-11-28 | 上海中医药大学附属曙光医院 | Method for filtering quiver wave by macroprogram |
| CN102799753B (en) * | 2011-05-27 | 2016-07-27 | 上海中医药大学附属曙光医院 | A kind of macroprogram filters the method for the ripple that trembles |
| CN102929789A (en) * | 2012-09-21 | 2013-02-13 | 曙光信息产业(北京)有限公司 | Record organizational method and record organizational structure |
| CN102929789B (en) * | 2012-09-21 | 2016-06-08 | 曙光信息产业(北京)有限公司 | Record organization method and record organization structure |
| CN105204708A (en) * | 2014-06-11 | 2015-12-30 | 株式会社Pfu | Information processing device and display method |
| CN104615652A (en) * | 2014-12-29 | 2015-05-13 | 曙光云计算技术有限公司 | Organization method for auxiliary records |
| CN104615652B (en) * | 2014-12-29 | 2018-05-29 | 曙光云计算集团有限公司 | A kind of method for organizing of auxiliary record |
| CN104915573A (en) * | 2015-07-01 | 2015-09-16 | 深圳市申泓科技有限公司 | Disease category processing platform based on smart health care |
| CN104915573B (en) * | 2015-07-01 | 2017-12-12 | 挂号网（杭州）科技有限公司 | Disease processing platform based on intelligent medical treatment |
| CN105550504A (en) * | 2015-12-09 | 2016-05-04 | 高玮 | Mobile medical information system and medical information processing method |
| CN105550504B (en) * | 2015-12-09 | 2018-03-23 | 珠海凯泓科技发展有限公司 | A kind of portable medical information system and medical information processing method |
| CN108776750A (en) * | 2018-04-20 | 2018-11-09 | 新疆维吾尔自治区胸科医院 | A kind of Drug-Resistant Mycobacterium tuberculosis base construction method |
| CN109785922A (en) * | 2018-12-14 | 2019-05-21 | 平安万家医疗投资管理有限责任公司 | A kind of method for uploading and system of medical history information |
| CN111524568A (en) * | 2020-04-24 | 2020-08-11 | 常州昊泽信息科技有限公司 | Electronic medical record retrieval system |
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