TW202008382A - Apparatus and method for establishing an electronic medical record - Google Patents

Abstract

A method for establishing an electronic medical record includes steps of converting a paper medical record into an electronic image, saving the electronic image into a database, and retrieving the electronic image via a first handheld device to create an electronic medical record image having a layer, whereby a user can further input a word, write a word, draw a picture, or paste a digital media file to input medical information on the electronic medical record image, and saving the electronic medical record image back to the database.

Description

Device and method for establishing electronic medical record

The invention relates to a device and method for establishing an electronic medical record, in particular to a device capable of converting a traditional paper medical record into an electronic medical record, and can directly write, draw, or even paste various types of digital media files in the electronic medical record Device and method for establishing electronic medical record.

With the advancement of technology, the traditional paper medical records are gradually replaced by electronic medical records, which not only allows medical personnel to quickly access medical records, saves the time of searching medical records and delivering medical records, but also overcomes the huge space occupied by paper medical records. The problem of not easy preservation, etc. makes each patient's important medical records be preserved for a long time.

However, the traditional electronic medical record system uses a standardized interface. Not only do medical staff need to re-learn the function menu and operation method of each medical record system, but also medical personnel can only enter patient data through the preset fields in the interface, For each patient's disease, because the diagnosis code of the same disease is the same, each patient is filled with the same system preset disease content, which can neither accurately describe the patient's condition nor draw a picture to record the patient The condition of the disease is not conducive to the follow-up of each patient's different conditions or the medical statistics of such diseases to promote medical progress.

In addition, the traditional electronic medical records are recorded with common digital characters. Even with the electronic signature, it is still impossible to distinguish whether the signature is approved by the physician himself, which allows interested persons to use this loophole to make violations.

The main purpose of the present invention is to provide an electronic medical record device and method, so that medical staff can record, draw, and even paste various types of digital media files directly in the electronic medical record through the handheld device, and will not be limited to traditional electronic The standardized menus and fields provided by the medical record system enable each patient's condition to be accurately recorded to facilitate tracking of the condition.

The secondary objective of the present invention is to provide an electronic medical record device and method for reading the textual meaning of handwritten text written by medical personnel on the electronic medical record, so that the electronic medical record can save the handwriting of medical personnel, so that each electronic medical record There are traces to solve the problem that the traditional electronic medical record system cannot know the identity of the recorder, and to avoid the problem of intentional people using the loopholes of the traditional electronic medical record system to use the signature. In addition, the handwritten text on the electronic medical record of the present invention can be read for search and other functions, while enhancing the credibility and practicality of the electronic medical record.

Still another object of the present invention is to provide an electronic medical record device and method for directly capturing electronic images of paper medical records to form an electronic medical record image with a layer, and using the electronic medical record image in the form of a virtual paper, The medical staff can directly write on the electronic medical record image to realize the establishment of the electronic medical record without re-learning the operation method of the new electronic medical record system, thereby improving the overall medical efficiency.

To achieve the above objective, the present invention provides a method for establishing an electronic medical record, including the following steps: converting a paper medical record into an electronic image; storing the electronic image in a database; in a first handheld device The electronic image is opened in order to form an electronic medical record image with a layer so that a user can further input a text, handwriting a text, draw a pattern, or paste a digital media file on the electronic medical record image, To create a medical information; and store the electronic medical record image in the database.

According to an embodiment of the present invention, the method further includes: uploading the electronic medical record image stored in the database to a server.

According to an embodiment of the present invention, the method further includes: recognizing the text handwritten on the electronic medical record image and inferring a textual meaning of the text, so that the first handheld device can read and write on the electronic medical record image The text meaning of the text.

According to an embodiment of the present invention, the method further includes: searching the text on the electronic medical record image according to a search condition, and displaying a search result in a sorted manner in a list.

According to an embodiment of the present invention, the method further includes: creating a layer on the electronic medical record image to further create the medical information in the layer on the electronic medical record image, so that when the medical information is modified An original content on the electronic medical record image.

According to an embodiment of the present invention, the method further includes: establishing an active medical record database, establishing multiple categories in the active medical record database, filtering the electronic medical record images and placing them in the multiple categories in an order One of them.

According to an embodiment of the present invention, the method further includes: signing the electronic medical record image, so that the user can perform a handwritten signature or affix a seal on an arbitrary position on the electronic medical record image.

According to an embodiment of the present invention, the method further includes: encrypting the electronic medical record image so that the user can access the electronic medical record image according to authority.

According to an embodiment of the invention, the method further includes: generating a code for the electronic medical record image, and transmitting the code to a second handheld device, which decodes the code, And read the electronic medical record image.

According to an embodiment of the invention, the method further includes playing the digital media file on the electronic medical record image.

The invention also provides another device for establishing an electronic medical record, including: an image capturing device for converting a paper medical record into an electronic image; a touch panel for receiving a touch signal and a data Input a signal and display the electronic image; an electronic medical record system is used to open the electronic image to form an electronic medical record image with a layer so that a user can edit the electronic medical record on the touch panel Image to further input a text, handwriting a text, draw a pattern, or paste a digital media file on the electronic medical record image; a storage for storing the electronic medical record image; and a communication device, connected to a A server, the communication device is used to upload the electronic medical record image to the server, and can access the electronic medical record image in the server.

According to an embodiment of the invention, wherein the server includes: a template database with an electronic image of a paper medical record template, the electronic medical record system accessing the paper from the template database through the communication device The medical record template; and a medical record database with the electronic medical record image, the medical record database is connected to the storage through the communication device, and the electronic medical record image in the storage is saved.

According to an embodiment of the present invention, the device further includes: a template database with an electronic image of a paper medical record template.

According to an embodiment of the present invention, wherein the electronic medical record system includes an encryption module for encrypting the electronic medical record image so that the user can access the electronic medical record image according to authority.

According to an embodiment of the present invention, wherein the electronic medical record system includes an analysis module, the analysis module is used to recognize the text handwritten on the electronic medical record image and calculate a text meaning of the text, so that the electronic medical record The system can directly read the text meaning of the text handwritten on the electronic medical record image.

According to an embodiment of the present invention, wherein the electronic medical record system includes a search module, searches the text on the electronic medical record image according to a search condition, and displays a search result in a sorted manner in a list.

According to an embodiment of the present invention, wherein the electronic medical record system includes an active medical record database, the active medical record database includes multiple categories, and the electronic medical record image is placed in the multiple categories according to a screening condition one of.

The invention provides a device and method for establishing an electronic medical record, so that medical personnel can directly record, draw, or even paste various types of digital media files in the electronic medical record through the handheld device, and will not be limited to the traditional electronic medical record system. The standardized menus and fields enable each patient's condition to be accurately recorded to facilitate tracking of the condition.

The device for establishing electronic medical records reads the literal meaning of the handwritten text written by medical staff on the electronic medical records, so that the electronic medical records can save the handwriting of medical personnel, so that each electronic medical record can be traced, solving the traditional electronic The problem that the medical record system cannot know the identity of the recorder makes the intentional person who has used the doctor's signature to take advantage of the loopholes of the traditional electronic medical record system to escape, protecting the rights and interests of the patient. In addition, the handwritten text on the electronic medical record can be read for search and other functions. Therefore, the device for establishing an electronic medical record of the present invention simultaneously improves the credibility and practicality of the electronic medical record.

The device for establishing an electronic medical record directly captures an image of a paper medical record, and converts the image into an editable electronic medical record image in the form of a virtual paper, so that medical personnel can directly write on the electronic medical record image to realize electronic The establishment of the medical record does not require re-learning the operation method of the new electronic medical record system, thereby improving the overall medical efficiency.

Other features and specific embodiments of the present invention can be further understood in the following detailed description with accompanying drawings.

10‧‧‧Establishment of electronic medical records

101‧‧‧Touch panel

102‧‧‧Image capture device

103‧‧‧Electronic medical record image

104‧‧‧stylus

105‧‧‧ First button

106‧‧‧Second button

107‧‧‧Storage

108‧‧‧Communication device

109‧‧‧ Active medical record database

11‧‧‧Second handheld device

12‧‧‧The first handheld device

13‧‧‧The third handheld device

14‧‧‧The fourth handheld device

15‧‧‧Patient

16‧‧‧ Nurse

17‧‧‧ Doctor

18‧‧‧Pharmacist

19‧‧‧Network communication

20‧‧‧Server

201‧‧‧ Template database

202‧‧‧ medical record database

203‧‧‧Data processor

204‧‧‧ Body Identification Module

205‧‧‧Data encryption module

31‧‧‧ paper medical records

32‧‧‧Electronic image

33‧‧‧Paper Medical Record Template

34‧‧‧Electronic medical records

40‧‧‧Electronic medical record system

401‧‧‧handwriting module

402‧‧‧Encryption module

403‧‧‧Analysis module

404‧‧‧Search module

50‧‧‧Entered text

51‧‧‧ handwritten text

52‧‧‧pattern

53‧‧‧ digital media files

54‧‧‧Seal

55‧‧‧ Signature

56‧‧‧layer

60‧‧‧ wish list

601‧‧‧ Donation wish list

61‧‧‧Outpatient

611‧‧‧Early diagnosis

612‧‧‧Lunch

613‧‧‧ Night Clinic

62‧‧‧ First diagnosis medical record

63‧‧‧ medical record database

631‧‧‧General

632‧‧‧Severe

633‧‧‧

634‧‧‧Auxiliary

64‧‧‧baby

641‧‧‧ baby

642‧‧‧Baby in Ward

65‧‧‧Reporting area

651‧‧‧ Inspection report

652‧‧‧pathology report

66‧‧‧Other

S101‧‧‧Convert a paper medical record into an electronic image

S102‧‧‧ Store the electronic image in a database

S103‧‧‧ The electronic image is turned on in a first handheld device to form an electronic medical record image with a layer so that a user can further input a text, handwrite a text, and draw on the electronic medical record image Design or paste a digital media file to create a medical information

S104‧‧‧ store the electronic medical record image in the database

S201‧‧‧Convert a paper medical record into an electronic image

S202‧‧‧ Store the electronic image in a database

S203‧‧‧ The electronic image is turned on in a first handheld device to form an electronic medical record image with a layer, and a layer is created on the electronic medical record image so that a user can use the electronic medical record image Enter a text, handwrite a text, draw a pattern, or paste a digital media file in this layer on the image to create a medical information

S204‧‧‧sign the electronic medical record image, so that the user can perform a handwritten signature or paste a stamp on an arbitrary position on the electronic medical record image

S205‧‧‧Encrypt the electronic medical record image

S206‧‧‧ Store the electronic medical record image in the database

S207‧‧‧Establishing an active medical record database, establishing multiple classifications in the active medical record database, screening the electronic medical record images and placing them in one of the multiple classifications in an order

S208‧‧‧Upload to a server

FIG. 1 is a schematic diagram of a device and a server for creating an electronic medical record according to an embodiment of the invention.

FIG. 2 is a schematic block diagram of a device for creating an electronic medical record according to an embodiment of the invention.

FIG. 3 is a schematic structural diagram of an active medical record database according to an embodiment of the present invention.

FIG. 4 is a flowchart of a method for establishing an electronic medical record according to an embodiment of the present disclosure.

FIG. 5 is a flowchart of another method for establishing an electronic medical record according to an embodiment of the present disclosure.

FIG. 6 and FIG. 7 are respectively three-dimensional schematic diagrams of a device for establishing an electronic medical record viewed from different angles according to an embodiment of the present invention.

In order to make the above and other objects, features, and advantages of the present invention more comprehensible, the preferred embodiments of the present invention will be specifically described below in conjunction with the accompanying drawings, which will be described in detail below. Furthermore, the terms of direction mentioned in the present invention, such as up, down, top, bottom, front, back, left, right, inner, outer, side, surrounding, center, horizontal, horizontal, vertical, longitudinal, axial, The radial direction, the uppermost layer or the lowermost layer, etc., are only the directions referring to the attached drawings. Therefore, the directional terminology is used to illustrate and understand the present invention, not to limit the present invention.

Please refer to FIGS. 1 to 3, FIG. 1 is a schematic diagram of a method for establishing an electronic medical record according to an embodiment of the present invention, and FIG. 2 is a method for establishing an electronic medical record according to an embodiment of the present invention A block schematic diagram of a device, and FIG. 3 is a schematic structural diagram of an active medical record database according to an embodiment of the present invention. A device 10 for establishing an electronic medical record of the present invention can be connected to each other via a network communication 19 to a server 20. The server 20 includes a template database 201, a medical record database 202, and a data processor 203. The device 11-14 can be selected from one of tablet, mobile phone and tablet computer.

As shown in FIG. 2, an electronic medical record creation device 10 according to an embodiment of the present invention includes an image capture device 102, a touch panel 101, an electronic medical record system 40, a storage 107, and a communication装置108。 The device 108. The image capturing device 102 converts a paper medical record 31 into an electronic image 32. In an embodiment of the invention, the paper medical record 31 may be more than or equal to one page, and each page in the paper medical record 31 is converted into an electronic image 32. The paper medical record 31 may be a blank paper medical record to create a paper medical record template 33, or the paper medical record 31 may also be a filled paper medical record to convert the filled paper medical record into an electronic Medical record 34. The image capturing device 102 may be a camera or a scanner. If the image capturing device 102 is a camera on the device 10, the device 10 is used to directly photograph the paper medical record 31, if the image is captured The taking device 102 is a scanner, and the paper medical record 31 is put into the scanner for scanning. The touch panel 101 is used to receive a touch signal and a data input signal, and display the electronic image 32. The touch panel 101 receives touch signals applied by the outside world on the touch panel 101 to control the electronic medical record In the system 40, the touch panel 101 displays a corresponding screen after receiving the data input signal, for example, when the touch panel 101 receives a data input signal of the electronic image 32, the electronic image is displayed 32 pictures.

The storage 107 is used to store the edited electronic medical record 34 and/or electronic medical record image 103. The storage 107 can receive the electronic medical record 34 from the server 20 and store it in the storage 107. The communication device 108 is connected to a server 20, and the communication device 108 may be via a wireless high-definition system (WiFi), Bluetooth, Bluetooth, MANET, Airdrop, and close range. Wireless communication (NFC), mobile communication technology (for example: 3G, 4G, 5G, etc.), global mobile communication system (GSM), integrated packet radio service system (GPRS), low-power mobile phone system (PHS), wireless area network system (WLAN) or Microwave Access Global Interoperability System (WIMAX), etc., upload the edited electronic medical record 34 and/or the electronic medical record image 103 to the server 20, and from the server 20 The electronic medical record 34 and/or the electronic medical record image 103 are accessed.

The template database 201 includes at least one paper medical record template 33, such as: consent form template, medical record template, surgical record template, instruction single template, medication record template, donation single template, blood drawing single template, inspection single template, birth Record templates, etc. The template in the template database 201 can come from the electronic image 32 captured by the image capturing device 102 on a paper medical record template 33.

The data processor 203 includes an identity recognition module 204 and a data encryption module 205. The identity recognition module 204 can manage the access rights of users 15-18 to the server 20. The data encryption module 205 can The electronic medical record 34 stored in the server 20 is encrypted.

The storage 107 of the device 10 can store at least one electronic image 32 of at least one paper medical record template 33. The storage 107 of the device 10 can store various templates, such as: consent form template, medical record template, surgical record template, instruction single template, medication record template, donation single template, blood drawing single template, test single template, birth Record templates, etc. The template in the storage 107 may come from the electronic image 32 captured by the image capturing device 102 on a paper medical record template 33.

The electronic medical record system 40 may be provided with a handwriting module 401, an encryption module 402, an analysis module 403, and a search module 404. The handwriting module 401 in the electronic medical record system 40 accesses the electronic image 32 and turns on the electronic image 32 to form an electronic medical record image 103 with a layer 56 so that a user (eg, a patient) 15. Nursing staff 16, physician 17, pharmacist 18, etc.) can edit the layer 56 of the electronic medical record image 103 through the touch panel 101 to further enter a text on the layer 56 of the electronic medical record image 103 ( (See 50 in Figure 6), handwriting a text (see 51 in Figure 6), drawing a pattern (see 52 in Figure 6), or pasting a digital media file (see 53 in Figure 6), etc. to create a Electronic Medical Record 34. The electronic medical record 34 may be more than or equal to one page of the electronic medical record image 103, and the electronic medical record image 103 may be a medical record form, a continuation of the medical record form, a test result, a consent form, a blood sample, a medical examination form Or arrears, etc., the handwriting module 401 can be set to automatically upload the electronic medical record 34 and/or the electronic medical record image 103 of the electronic medical record 34 to the server 20 in real time to update the server 20 in real time的该电子 Medical records 34.

The electronic medical record system 40 accesses a paper medical record template 33 from the template database 201 in the server 20 through the communication device 108, and a medical record database 202 in the server 20 is connected to the Storage 107, and save the electronic medical record 34 and/or the electronic medical record image 103 in the storage 107 in the medical record database 202, wherein the electronic medical record image 103 may be a consent form, medical records, surgical records , Instructions, dosing records, donation slips, blood draws, test slips, birth records, etc. The electronic medical record 34 in the medical record database 202 may come from at least one electronic image 32 captured by the image capture device 102 for a paper medical record 31 or from the electronic record created by the device 10 for creating electronic medical records For the electronic medical record 34, since the paper medical record 31 may have at least one page, the electronic medical record 34 created by the paper medical record 31 may have at least one page of the electronic medical record image 103.

According to an embodiment of the present invention, a newly diagnosed patient 15 uses a handheld device 11 to access at least one paper medical record template 33 in the template database 201 via a network communication 19, and the paper medical record template 33 Write or enter basic personal information, such as: name, birthday, gender, ID number, address, phone number, name and phone number of emergency contact person, blood type, drug allergy record, medication being taken, disease, etc., to establish a The newly diagnosed medical record 62, through the communication device 108 using the network communication 19 to transmit the newly diagnosed medical record 62 to the medical record database 202, a nurse 16 uses a handheld device 12 to access the newly diagnosed medical record 62 through the network communication 19, and Write the results of the basic examination of the patient 15 in the initial medical record 62, such as height, weight, blood pressure, heartbeat, body temperature, etc., and send it to the medical record database 202 through the network communication 19, a physician 17 Use a hand-held device 13 to access the newly diagnosed medical consultation 62 through the network communication 19 for the patient 15 to see and conduct consultations, write the medical condition, medical order and prescription in the newly diagnosed medical record 62, and transfer the newly diagnosed medical record 62 Transmitted to the medical record database 202 via the network communication 19, a pharmacist 18 accesses the prescription through the handheld device 14 via the network communication 19, and dispenses the patient 15.

The electronic medical record system 40 may be provided with an encryption module 402 for encrypting the electronic medical record image 103 so that the user 15-18 can access the electronic medical record image 103 according to the authority. According to an embodiment of the present invention, after the electronic medical record image 103 finishes editing, the encryption module 402 generates a code, sets a password lock, sets fingerprint identification lock, and sets face identification lock for the electronic medical record image 103 Or any method such as setting pupil identification lock, encrypt the electronic medical record image 103 and upload it to the server 20. According to another embodiment of the invention, an encryption module 402 of a handheld device 13 of a physician 17 generates a code for the electronic medical record image 103 and transmits the code to a second hand of a patient 15 In the handheld device 11, the second handheld device 11 of the patient 15 decodes the code and reads the electronic medical record image 103. The code may be one of one-dimensional code, two-dimensional code, QR-code and so on. The method and device 10 for establishing an electronic medical record of the present invention can also be used to encrypt a large amount of data such as test reports, health education slips, mother's manuals, parent-child manuals, etc., and send it to a user, for example: a patient 15 or medical staff 16-18.

The electronic medical record system 40 can be provided with an analysis module 403 for recognizing the text handwritten on the layer 56 on the electronic medical record image 103 (see 51 in FIG. 6) and estimating the text A text meaning of 51 enables the electronic medical record system 40 to directly read the text meaning of the text 51 handwritten on the layer 56 of the electronic medical record image 103. The identification may be performed by a comparison method, and the comparison method may include comparing the handwritten character 51 with a plurality of characters in a character library. The analysis module 403 may be a process in which a user 15-18 writes a text 51 on a touch panel of the handheld device 11-14, compares the text 51, and calculates a meaning of the text 51, Compare and record the literal meaning of each handwritten text 51. The analysis module 403 may also compare and sum the text 51 on the layer 56 of the electronic medical record image 103 when it is necessary to acquire all the handwritten text 51 on the layer 56 of the electronic medical record image 103 The meaning of a character of the character 51 is estimated. The analysis module can read rows and columns in the image of each handwritten character 51 in a two-dimensional array, and convert it into at least one independent character matrix, and the character matrix and a character library Multiple characters are compared to calculate a meaning of the text corresponding to the handwritten text 51, so that the handwritten text 51 on the layer 56103 of the electronic medical record image is shown as handwritten handwriting, but it can be The electronic medical record system 40 reads and selects. If the compared text is a language composed of multiple letters in a single word (for example: English, Latin, German, Italian, etc.), the character to be compared is the letter in the language. If the compared text is formed by radicals and parts or other methods (for example: Chinese, Korean, etc.), the character to be compared is the text itself, and if the compared text is Arabic numerals, then The character to be compared is a number. If the compared text is a punctuation mark (for example: ",", ".", ",", ".", etc.), the character to be compared is The text itself. The handwritten text 501 on the layer 56 of the electronic medical record image 103 in FIG. 6 uses English'Disease' as an example, then it is compared as'D','i','s','e', 'a','s','e'. If the handwritten text on the layer 56 of the electronic medical record image 103 is "disease", it is compared as "ill" and "ill". If the handwritten text on the layer 56 of the electronic medical record image 103 is "123.4", it is compared to "1", "2", "3", ".", and "4".

The electronic medical record system 40 may be provided with a search module 404. The search module obtains the text meaning of the plurality of texts on the layer 56 of the electronic medical record image 103 through the analysis module 403, and searches the electronic medical record according to a search condition The content on the layer 56 of the image 103 that meets the search conditions and displays a search result in a sorted manner in a list. The search module 404 can also search a database 201, 202 to search for the data The layers 56 of the electronic medical record images 103 in the libraries 201 and 202 that meet a search condition, and display a search result in a sorted manner in a list. The search condition may be at least one text, at least one number, or a combination of at least one text and at least one number, and the sorting method may be by date, medical record number, patient's birth date, name stroke, classification of medical record, and degree of matching the search result Wait for one of them.

In an embodiment of the present invention, the electronic medical record file 103 or the electronic medical record 34 may be stored in a format readable and editable by the electronic medical record system 40 or a PDF format, which may be further preserved and/or With the password locked, the medical staff 16-18 can send the electronic medical record image file 103 or the PDF of the electronic medical record 34 to the patient 15 via network communication 19. In an embodiment of the present invention, after the doctor 17 makes a diagnosis, a digital media file 53 (eg, X-rays) is handwritten, input, drawn, or pasted on the layer 56 on the electronic medical record image 103 of the patient 15 , Ultrasound images, etc.), and even annotate on the digital media file 53, and can copy the medical information to a referral form or an insurance declaration form, save it as a PDF format, through the network communication 19 The second hand-held device 11 in which the PDF is transmitted to the patient 15 saves the time required for the traditional paper medical record and the traditional electronic medical record system to rewrite the referral form or insurance declaration form, and saves the traditional paper medical record Compared with the traditional electronic medical record system, the digital media file 53 needs to be burned in an optical disc, which saves the patient unnecessary expenses and enables more money to be applied to the treatment.

Through the device 10 and method for establishing an electronic medical record of the present invention, the patient 15 can also directly use the device 10 in the electronic medical record image file 103 (for example: medical record exchange consent, simultaneous anesthesia, surgical consent, donation consent) Or the power of attorney, etc.), so that the electronic medical record file 103 is directly stored in the electronic medical record 34, saving the printing of the electronic medical record file 103 for the patient 15 to sign and scan the electronic medical record file 103 Steps and time of filing. When the patient 15 signs on the device 10, the present invention can also directly connect the signed electronic medical record file 103 to a printer via network communication 19 to print a copy to the patient 15 or directly transfer the signed electronic medical record file 103 to the second handheld device 11 of the patient 15 through the network communication 19, the transmission may be to encrypt the signed by the encryption module 402 A consent form to generate a code and send it to the second handheld device 11 of the patient 15 to decode the code and read the copy of the signed consent form of the electronic medical record image.

The electronic medical record system 40 may be provided with an active medical record database 109, and the electronic medical record image 103 is placed in one of the plurality of classifications according to a screening condition. The screening condition may be the patient 15's visit time ( For example: early diagnosis, lunch diagnosis and night diagnosis), the severity of the patient 15 (for example: general and severe), the type of the patient 15 (for example: general and infant) or the type of the electronic medical record image 103 itself (for example : Wish list, medical record and report) etc. The active medical record database 109 can be connected to the server 20 to access the electronic medical record 34 in the server 20 and upload the edited electronic medical record 34 to update the electronic medical record 34 in the server 20 synchronously. As shown in Figure 3, the active medical record database 109 includes multiple categories 60-66. The classification includes: wish list 60, today's clinic 61, initial medical record 62, medical record database 63, infant 64, report area 65, other 66 Etc., the other 66 may be a temporary storage area, ward records or other classifications. The medical staff 16-18 may establish the required classification and its sub-categories according to needs. The temporary storage area temporarily stores the deleted electronic medical record image 103; The ward records store ward-related records. Each category 60-66 may include multiple sub-categories 601, 611-613, 631-634, 641-642, and 651-652.

The wish list 60 may include a donation wish list 601, etc., which stores the donation wish lists of multiple patients 15 for donated organs or tissues (eg, sperm, eggs, etc.).

Today's outpatient clinic 61 may include an early clinic 611, a midnight clinic 612, and a night clinic 613, etc. The medical staff can select the entire electronic medical record 34 or an electronic medical record image 103 of the patient who has made an appointment for today's appointment from the medical record database 63, and press A sort is sorted into the corresponding category, for example: the entire electronic medical record 34 of a patient who has reserved 9 am to 12 noon or an electronic medical record image 103 is classified as an early diagnosis 611, and a reservation is made from 12 am to afternoon The entire electronic medical record 34 or an electronic medical record image 103 of a patient at 18 o'clock is classified as a lunch clinic 612, and the entire electronic medical record 34 or an electronic medical record image 103 of a patient who has reserved an appointment from 7 pm to 10 pm It is classified as night clinic 613, and the sorting may be one of the following: time of consultation, registration order, medical record number, patient's date of birth, name stroke, classification of medical record, etc.

The initial medical record 62 stores the electronic medical record 34 of the patient 15 at the first visit.

The medical record database 63 may include general 631, severe 632, confinement 633, and auxiliary 634; the medical record database 63 stores electronic medical records 34 of all patients, and is classified according to the degree of the disease, so that the nursing staff 16-18 can quickly find the corresponding Electronic medical records 34, general patients are classified as general 631, patients with major diseases are classified as severe 632, confinement services are classified as confinement 633, and those who need assisted conception The patient is classified as an assistant 634. The medical record database 63 can be connected to another server to backup all electronic medical records 34 in the medical record database 63, further protect the electronic medical records 34 of the patient 15, and improve the establishment of the present invention The reliability of the method and device 10 of the electronic medical record.

Babies 64 may include confinement 641 and ward 642, etc. Confinement 641 is the electronic medical record 34 of babies living in a general nursery room 34, birth records, results of various inspection reports, etc. Ward babies 642 are stored in The medical records, birth records, and results of various inspection reports of the baby in the ward.

The report area 65 may include an inspection report 651 and a pathology report 652, etc. The inspection report 651 stores reports of various inspections. Nursing staff (for example, a nurse 16 or a medical examiner) can access a patient 15 through this report area Test report, and print the test report and hand it to the patient 15, or through the encryption module 402 of the electronic medical record system 40, generate a corresponding code of the test report, for example: QR-code, through a handheld The device 12-14 sends the code to a handheld device 11 of the patient 15, and decodes the code in the second handheld device 11 of the patient 15, and reads the electronic medical record image 103.

According to an embodiment of a device 10 for creating medical records according to the present invention, the active medical record database 109 is the medical record database 202 stored in the storage 107 of the device 10, the server 20, and the medical personnel 16 -18 A mobile device 11-14 can be used to open the mobile medical record database 109, select an electronic medical record image 103, and place the selected electronic medical record image 103 in one of the multiple categories according to a screening condition One. The screening condition may be the visiting time of the patient 15, the severity of the patient 15, the type of the patient 15, or the type of the electronic medical record image 103. According to an embodiment of the present invention, the patient 15 has reserved an appointment for the noon consultation period, and a nurse 16 searches for the medical record database 63 through a search module 404 through a device 10 for creating an electronic medical record of the present invention The electronic medical record 34 of the patient 15 moves the electronic medical record 34 from the medical record database 63 to the lunch clinic 612 in the today's clinic 61 according to the appointment time scheduled by the patient 15, and the physician 17 passes The device 10 accesses the electronic medical record 34 of the patient 15 from the afternoon clinic 612 of the today's clinic 61, and inputs at least one text 50 through the handwriting module 401, handwriting at least one text (51 in FIG. 6), Draw at least one pattern (52 in Figure 6) or paste at least one digital media file (53 in Figure 6) to record the condition of the patient 15. After the consultation, the nurse 16 The electronic medical record 34 moves back to the medical record database 63.

The mobile medical record database 109 of the present invention can, on the one hand, move the electronic medical record 34 of a patient 15 to a specific category according to a screening condition, so that the relevant nursing staff 16-18 can control the number of patients 15 in each category , Or to control the situation of special patients, etc., so that the medical staff responsible for the relevant matters of the classification 16-18 can easily grasp the real-time information of the classification, for example: how many patients are still waiting for medical treatment, surgery, inspection or dispensing, etc. On the other hand, effectively manage the authority of medical staff 16-18 to electronic medical record 34, the medical staff 16-18 can only access the electronic medical record 34 of the patient 15 of the department they belong to, for example: the doctor responsible for today’s lunch 17 can only access the electronic medical records 34 of the patients in the lunch clinic 612, and the medical examiner responsible for the inspection can only access the electronic medical records 34 of the patients waiting for inspection, which should avoid the problem of excessive authority of the medical staff to protect the patients The privacy also avoids problems such as electronic medical records 34 or tampering of electronic medical records 34 that medical personnel mistakenly input into other patients.

FIG. 4 is a flowchart of a method of establishing an electronic medical record according to an embodiment of the present disclosure, and FIG. 5 is a flowchart of another method of establishing an electronic medical record according to an embodiment of the present disclosure. As shown in FIG. 4, the present invention provides a method for establishing an electronic medical record, including the following steps: S101: converting a paper medical record 31 into an electronic image 32, wherein the paper medical record 31 may be more than or equal to One page, and each page in the paper medical record 31 is converted into an electronic image 32; S102: storing the electronic image 32 in a database 201, 202; S103: a first handheld device Turn on the electronic image 32 in 12 to form an electronic medical record image 103 with a layer 56 so that a user 15-18 can further enter a text on the electronic medical record image 103 (see 50 in FIG. 6) , Handwriting a text (see 51 in Figure 6), drawing a pattern (see 52 in Figure 6), or pasting a digital media file (see 54 in Figure 6) to create a medical information; S104: The electronic medical record image 103 is stored in the databases 201, 202.

In step S103, the digital media file 53 may be one of images, videos, recordings, etc. The digital media file may be captured by the image capturing device 102 of the electronic medical record creation device 10, the figure The image may be a medical imaging image such as ultrasound or X-ray. The video may be a medical imaging image such as ultrasound or X-ray. The recording may be recorded by a recording device of the electronic medical record creation device 10, the digital The media file 53 can be directly played on the electronic medical record image 103 or a playback program of the electronic medical record creation device 10.

As shown in FIG. 5, the present invention provides another method for establishing an electronic medical record, including the following steps: S201: Convert a paper medical record 31 into an electronic image 32, where the paper medical record 31 may be more than or Equal to one page, and each page in the paper medical record 31 is converted into an electronic image 32; S202: storing the electronic image 32 in a database 201, 202; S203: a first handheld The electronic image 32 is turned on in the device 12 to form an electronic medical record image 103 with a layer 56 so that a user 15-18 can further input a text on the electronic medical record image 103 (see 50 in FIG. 6) ), handwriting a text (see 51 in Figure 6), drawing a pattern (see 52 in Figure 6), or pasting a digital media file (see 54 in Figure 6) to create a medical information; S204: Yes The electronic medical record image 103 is signed, so that the user 15-18 can perform a handwritten signature (see 55 in FIG. 6) or paste a seal drawing (see section 54 in Figure 6); S205: encrypt the electronic medical record image 103; S206: store the electronic medical record image 103 in the database 201, 202; S207: establish an active medical record database 109, in the active medical record A plurality of categories 60-66 are created in the library 109, the electronic medical record image 103 is screened and placed in one of the plurality of categories 60-66 in an order; and S208: upload to a server 20.

Wherein, in step S203, the digital media file 53 may be one of images, videos, audio recordings, etc. The digital media file may be captured by the image capturing device 102 of the electronic medical record creation device 10, the figure The image may be a medical imaging image such as ultrasound or X-ray. The video may be a medical imaging image such as ultrasound or X-ray. The recording may be recorded by a recording device of the electronic medical record creation device 10, the digital The media file 53 can be directly played on the electronic medical record image 103 or a playback program of the electronic medical record creation device 10.

In a method for creating an electronic medical record according to an embodiment of the present invention, the method further includes: generating a code for the electronic medical record image 103, and transmitting the code to a second handheld device 11, the second hand The holding device 11 decodes the code and reads the electronic medical record image 103.

In a method for creating an electronic medical record according to an embodiment of the present invention, the method further includes: connecting a printer via network communication 19 to print the electronic medical record image 103. The method of establishing an electronic medical record of the present invention can print the entire electronic medical record 34, and even print out the relevant data of the medical record form of the entire database, so that all electronic medical records 34 are printed immediately when the health insurance bureau conducts a random review and submitted directly to Health Insurance Bureau.

Please refer to FIG. 6 and FIG. 7, FIG. 6 and FIG. 7 are schematic structural views of an apparatus 10 for establishing an electronic medical record viewed from opposite perspectives according to an embodiment of the present invention. The device 10 is provided with an image capturing device 102, a touch panel 101, an electronic medical record system 40, a storage 107, and a communication device 108. The image capturing device 102 converts a paper medical record 31 into an electronic image 32. In an embodiment of the present invention, the paper medical record 31 may be more than or equal to one page, and each page in the paper medical record 31 is converted into an electronic image 32, and multiple paper medical records The electronic images 32 are stored in the same storage path to create an electronic medical record 34 of the patient, the storage path may be linked to the server 20, the template database 201 in the server 20, the server The medical record database 202 in 20 or the storage 107 of the device 10. The electronic medical record 34 can be manually named or automatically named by the electronic medical record system 40. The electronic medical record 34 can be named according to the patient's identity card number, unified certificate number, name, birthday, etc. The electronic medical record system 40 can be automatically generated A sequential code or random code.

The image capturing device 102 may be a camera, and the device 10 may photograph the paper medical record 31 to obtain an electronic image 32. The image capturing device 102 may be connected to a driver program to adjust the contrast, brightness, angle, or alignment of the paper medical record 31 for the electronic image 32 to increase the clarity of the electronic image 32.

The touch panel 101 may be a resistive touch panel, a capacitive touch panel, or a wave touch panel. The touch panel 101 receives touch signals and data input signals from the stylus 104 or fingers. If the touch panel 101 is a resistive touch panel, it is pressed by using the stylus 104 or fingers. The upper and lower electrodes of the touch panel 101 are brought into contact, causing a voltage change to generate the touch signal; if the touch panel 101 is a capacitive touch panel, the panel capacitance is affected by the stylus 104 or finger to calculate The touch signal is generated at the contact position; if the touch panel 101 is a wave-type touch panel, a grid is formed by the surrounding transmitters and receivers, and the signal blocked by the stylus 104 or fingers is detected by detection To generate the touch signal. The data input signal may come from handwriting input or pressing the keyboard on the touch panel 101.

The electronic medical record system 40 forms the electronic image 32 into an electronic medical record image 103 with at least one layer 56 so that a user 15-18 can edit the electronic medical record image 103 on the touch panel 101 to The electronic medical record image 103 is further input with a text 50, handwritten text 51, drawing a pattern 52, or pasting a digital media file 53. The electronic medical record system 40 can be a built-in system, a mobile application (app) or a software. The electronic medical record system 40 may be built in the electronic medical record creation device 10 or the handheld device 11-14 as a built-in system, or installed in the handheld device 11-14 in the form of a mobile application . In an embodiment of the present invention, when a user 15-18 edits on the electronic medical record image 103 (for example: handwriting, drawing or pasting a digital media file), the handwriting module 401 can be in the original Editing on layer 56, you can also add at least one layer 56 on the electronic medical record image 103, or you can add at least one layer 56 by users 15-18 according to actual needs, to further handwrite a text 51, draw a pattern 52 Or paste a digital media file 53, for example: the handwritten text 51 is a first layer, the input text 50 is a second layer, the pattern 52 is a third layer and the digital media file 53 is a first Four layers, so that different contents are located in separate layers, and each of the multiple layers can be modified or moved separately, for example, to move one of the multiple layers to another place. In addition, the multiple layers may overlap with each other, for example, a user 15-18 may place the first layer with the handwritten text 51 on the digital media file 53 of the fourth layer, or on the A fifth layer with another handwritten text is added to the digital media file 53 of the fourth layer to add a note to the digital media file 53 to better describe the condition of the patient 15. In an embodiment of the present invention, since the layer 56 is set on the electronic image 32 so that the electronic image 32 is used as a background without being edited, the layer 56 may be in the form of a virtual paper, a user 15-18 can be further edited on the layer 56, the layer can be transparent or presented in other colors, the layer 56 can be the same or substantially the same size as the electronic image 32, the layer 56 can also be the same as the input The size of the text 50, the handwritten text 51, the pattern 52 or the digital media file 53 is the same or substantially the same. In an embodiment of the invention, the layer 56 may be one of a text box, a picture box, a canvas or a digital media file box, etc., and the layer 56 may be selected by clicking on the electronic medical record image 103 , Move the layer 56 to another place on the electronic medical record image 103. When handwriting a text 51 or drawing a pattern 52 on the electronic medical record image 103, the text 51 or the pattern 52 may be set to be immovable so as not to be moved or tampered with. In the device 10 and method for creating an electronic medical record of the present invention, a user 15-18 can further adjust the size of the digital media file 53 and can reduce the digital media file 53 to save the electronic medical record image 103 Space, enlarge the digital media file 53 when you need to view, to view the digital media file 53 more clearly.

A user 15-18 can also use the handwriting module 401 of the electronic medical record system 40 to sign the electronic medical record image 103, so that the user 15-18 can use the electronic medical record image as a virtual paper A handwritten signature 55 or a stamp image 54 is affixed to an arbitrary position on 103. In an embodiment of the invention, a user (eg, a doctor 17) writes a diagnosis result on the electronic medical record image 103 of the patient 15, and then signs 55 on the electronic medical record image 103, and / Or paste the seal map 54 for stamping. The seal map 54 can be locked with a password, fingerprint comparison, face comparison, or pupil comparison, so that only the person can access the seal map 54 or the seal map 54 can be stored in an account so that the use The person 17 accesses the seal map 54 of the user 17 according to the authority. In an embodiment of the present invention, the electronic medical record image 103 may be a consent form or a power of attorney, for example: a medical record exchange consent form, a simultaneous anesthesia form, a surgical consent form, a donation consent form, a medical record commission form or medicine On behalf of the power of attorney, etc., the patient 15 may sign 55 or seal 54 the consent or power of attorney.

At least one button 105, 106 can be displayed on the electronic medical record system 40. The button 105, 106 receives a signal from a stylus 104 or a finger and executes an instruction. The first button 105 is a function of adding a page. When the stylus 104 or the finger is used to click the first button 105, a page is added. The first button 105 also has a current display according to the electronic medical record system 40 Interface to determine the types of pages that can be added. If the currently displayed interface is a list of multiple electronic medical record images 103 of the main selected multiple categories 60-66 or its sub-categories 601, 611-613, 641-642, then the first button 105 The function is to add a newly created electronic medical record 34 to the category 60-66 or its sub-categories 601, 611-613, 641-642. The electronic medical record 34 may include at least one electronic medical record image 103; if currently displayed When the interface is an electronic medical record image 103 in an electronic medical record 34, the function of the first button 105 is to add a new electronic medical record image 103 in front of or behind the electronic medical record image 103. The new The electronic medical record image 103 may be a medical record sheet, a continuation sheet of a medical record sheet, an inspection form, a consent form, a prescription, a blood draw list, a medical examination form, an arrears form, a reminder list, or an observation list in the hospital. In an embodiment of the present invention, the medical staff 16-18 may add a reminder list in front of the home page of the electronic medical record 34 of the patient 15 to track the unfinished items of the patient 15, for example: regular Blood tests, various test items to be carried out, etc.

The second button 106 may have a function of displaying a plurality of options 60-66 of the active medical record library 109. When the second button 106 is clicked by using the stylus 104 or the finger, the touch panel 101 The options of multiple categories 60-66 of the active medical record database 109 appear, and when one of the multiple categories 60-66 is further clicked, the child included in the selected category 60-66 will be displayed Options for categories 601, 611-613, 641-642, 651-652, a user 15-18 can click on multiple categories 60-66 or subcategories 601, 611-613, 641 of the active medical record database 109 -642, to view a list of a plurality of electronic medical record images 103 of each category 60-66 or its subcategories 601, 611-613, and 641-642.

The present invention provides a device and method for creating an electronic medical record, so that medical personnel can directly record and draw in the electronic medical record through a handheld device, and paste various types of digital media files. The device and method for creating an electronic medical record of the present invention are not limited to The standardized menus and fields provided by the traditional electronic medical record system enable each patient's condition to be accurately recorded to facilitate tracking of the condition.

The device for establishing an electronic medical record reads the literal meaning of handwritten text written by medical personnel on the electronic medical record, so that the electronic medical record can save the handwriting of medical personnel, so that each electronic medical record can be traced, and the doctor and patient are identified. The handwriting and signature of various medical documents solve the problem that the traditional electronic medical record system cannot know the identity of the writer, so that the intentional person who uses the loophole of the traditional electronic medical record system to impersonate the doctor’s signature has nothing to hide, protecting the patient’s The rights and interests also solve the problem that the traditional electronic medical record system cannot allow patients to sign consents on the system, saving a lot of paper. In addition, the handwritten text and the entered text on the electronic medical record of the present invention can be read and searched. Therefore, the device for establishing an electronic medical record of the present invention also solves the shortcomings of traditional paper medical records that are not easy to find, and It solves the loophole that the traditional electronic medical record system can not distinguish the author, and greatly improves the credibility and practicality of the electronic medical record.

The invention directly captures the electronic image of the paper medical record to form an electronic medical record image with one layer, and the electronic medical record image is in the form of a virtual paper so that medical personnel can directly write on the electronic medical record image, To establish an electronic medical record, medical staff do not need to re-learn and get used to the operation method of the new electronic medical record system. It also avoids the problem of not being able to properly record the patient's condition due to lack of operation or unfamiliarity with the system.

Although the present invention has been disclosed in preferred embodiments, it is not intended to limit the present invention. Anyone who is familiar with this skill can make various changes and modifications without departing from the spirit and scope of the present invention. Therefore, the present invention The scope of protection shall be as defined in the scope of the attached patent application.

S101‧‧‧Convert a paper medical record into an electronic image

S102‧‧‧ Store the electronic image in a database

S103‧‧‧ The electronic image is turned on in a first handheld device to form an electronic medical record image with a layer so that a user can further input a text, handwrite a text, and draw on the electronic medical record image Design or paste a digital media file to create a medical information

S104‧‧‧ store the electronic medical record image in the database

Claims (17)

A method for establishing an electronic medical record includes the following steps: converting a paper medical record into an electronic image; storing the electronic image in a database; opening the electronic image in a first handheld device to form An electronic medical record image with a layer so that a user can further input a text, handwriting a text, draw a pattern, or paste a digital media file on the electronic medical record image to create a medical information; and Electronic medical record images are stored in the database. The method for establishing an electronic medical record according to item 1 of the patent application scope further includes: uploading the electronic medical record image stored in the database to a server. According to the method for establishing an electronic medical record according to item 1 of the patent application scope, the user further adds the layer to the electronic medical record image. The method for establishing an electronic medical record according to item 1 of the patent application scope further includes: recognizing the text handwritten on the electronic medical record image and calculating a text meaning of the text so that the first handheld device can read the electronic medical record The text meaning of the text handwritten on the image. The method for establishing an electronic medical record according to item 3 of the patent application scope further includes: searching the text on the electronic medical record image according to a search condition, and displaying a search result in a list in a sorted manner. The method for establishing an electronic medical record according to item 1 of the patent application scope also includes: maintaining the original content on the electronic medical record image when modifying the medical information. The method for establishing an electronic medical record according to item 1 of the patent application scope also includes: establishing an active medical record database, establishing multiple classifications in the active medical record database, screening the electronic medical record images and placing them in an order One of the multiple categories. The method for establishing an electronic medical record according to item 1 of the patent application scope also includes: signing the electronic medical record image so that the user can perform a handwritten signature or paste on an arbitrary position on the electronic medical record image Seal map. The method for establishing an electronic medical record according to item 1 of the patent application scope further includes: encrypting the electronic medical record image so that the user can access the electronic medical record image according to authority. The method for establishing an electronic medical record according to item 1 of the patent application scope further includes: generating a code for the electronic medical record image, and transmitting the code to a second handheld device, the second handheld device The code is decoded and the electronic medical record image is read. A device for establishing electronic medical records includes: an image capturing device for converting a paper medical record into an electronic image; a touch panel for receiving a touch signal and a data input signal, and displaying the An electronic image; an electronic medical record system for turning on the electronic image to form an electronic medical record image with a layer so that a user can edit the electronic medical record image on the touch panel Enter a text, handwriting a text, draw a pattern, or paste a digital media file on the electronic medical record image; a storage for storing the electronic medical record image; and a communication device connected to a server, the communication device It is used to upload the electronic medical record image to the server, and can access the electronic medical record image in the server. The device for establishing an electronic medical record according to item 11 of the patent application scope, wherein the server includes: a template database with an electronic image of a paper medical record template, and the electronic medical record system retrieves data from the template through the communication device The paper medical record template is accessed in the library; and a medical record database with the electronic medical record image, the medical record database is connected to the storage through the communication device, and the electronic medical record image in the storage is saved. The device for establishing an electronic medical record according to item 11 of the scope of patent application further includes: a template database with an electronic image of a paper medical record template. The device for establishing an electronic medical record according to item 11 of the patent application scope, wherein the electronic medical record system includes an encryption module for encrypting the electronic medical record image so that the user can access the electronic medical record image according to authority. A device for establishing an electronic medical record according to item 11 of the patent application scope, wherein the electronic medical record system includes an analysis module for identifying the text handwritten on the electronic medical record image and a text for inferring the text Meaning, so that the electronic medical record system can directly read the text meaning of the text handwritten on the electronic medical record image. A device for establishing an electronic medical record according to item 15 of the patent application scope, wherein the electronic medical record system includes a search module, searches for the text on the electronic medical record image according to a search condition, and displays them in a list in a sorted manner A search result. A device for establishing an electronic medical record according to item 11 of the patent application scope, wherein the electronic medical record system includes an active medical record database, the active medical record database includes multiple categories, and the electronic medical record image is placed in accordance with a screening condition One of the multiple categories.

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