TW202232514A - Auxiliary medical report generating system - Google Patents

Abstract

An auxiliary medical report generating system is disclosed. It includes a data collection module, a list module, a database module, a medical report generating module, a graphic display module, and a device data acquisition module. Using the historical data in the database module, the medical report generating module can generate relevant medical report drafts, so that medical personnel can reduce the occurrence of errors when writing medical reports. At the same time, the graphic display module of the present invention can automatically add explanatory diagrams to the medical report, and the device data acquisition module can also dynamically acquire the data of an external equipment and add it to the medical report as a reference. The invention effectively reduces the time cost of the medical personnel on the medical reports and increases the content of the medical reports as well.

Description

Auxiliary generation system of medical report

The present invention relates to an auxiliary report generation system, in particular to a medical report auxiliary generation system, which can reduce the time spent by medical institution staff in preparing medical reports and increase work efficiency.

The rapid progress of modern medical research and the innovation of related medical equipment have enabled people to enjoy high-quality medical services. In this era of leaping forward in human well-being, the source of great contributions is the hard work of countless medical staff, who combine their own experience with teamwork to reflect in the recovery of patients' diseases and alleviation of pain. However, it is foreseeable that due to the improvement of medical quality, many corresponding chores will also increase. These chores may seem trivial to outsiders, but to the medical staff they are the straws that are constantly added to the camel's body. In addition to increasing the cost of the overall medical system, it may also inadvertently cause medical staff to worry about the disease and the disease. misjudgment. One of these chores is writing medical reports.

A medical report, such as an operation report, requires the doctor to make a complete description and analysis of the patient's clinical data, pre-surgery examination, equipment used in the operation, the body parts used by the equipment, and the operation results. For specialists, based on their rich surgical experience, it is not difficult to issue a surgical report. But because there are no auxiliary tools, the writing of a surgical report needs to start from scratch. In order to save time, many doctors have the practice of preparing their own manuscripts; that is, classifying patients according to the lesions and treatment methods, arranging several report manuscripts in advance, and modifying a more suitable manuscript when a report is required. Surgical reports often need to fill in a lot of clinical data, although these data can be obtained from the Hospital Information System (HIS), and copied and pasted by writing software To meet the needs of the relevant format, but the doctor's working hours are in a hurry, it is inevitable that the data in the report will be filled in errors due to carelessness. These erroneous data may not be viewed again, but they are more likely to become medical history years later, and it is risky for the next doctor to rely on the wrong historical data to determine the patient's current condition. In addition, modern medical reports often contain many auxiliary explanatory graphics, and medical personnel need to write explanations or paste test reports on relevant positions. This kind of purely human-operated reporting operation is unavoidable. It is meaningful that many medical inspection equipments now provide the function of outputting result files, but whether it can be integrated into the auxiliary explanatory graphics in the report still needs the efforts of medical information practitioners.

Therefore, the medical community needs a report-assisted generation system to solve the above-mentioned problems.

This text extracts and compiles certain features of the invention. Other features will be disclosed in subsequent paragraphs. It is intended to cover various modifications and similar arrangements within the spirit and scope of the appended claims.

In order to solve the aforementioned problems, the present invention discloses a medical report auxiliary generation system. The system can be installed in a server host, and includes: a data collection module, which obtains the patient's personal basic information through a first interface provided on an operating terminal; a list listing module, which is provided on the operating terminal through a first interface The second interface provides medical personnel to select body parts, treatment items, used devices and/or drugs related to medical reports, and the operation sequence of treatment items; a database module that stores body parts, treatment items, used devices and/or drugs, and a history record of combinations of operation sequences of processing items, wherein each combination corresponds to a diagnosis result of a patient; and a medical report generation module, which performs the following tasks: through a medical report format, data from the first interface and the second Fill in the corresponding fields with the data in the interface; organize the corresponding body parts and used devices and/or drugs into a description text according to the operation sequence of the treatment items, and list the corresponding patient diagnosis results in the database module in the description the end of the sentence to form a final draft; through the A third interface examines and adjusts the information in the fields, and allows medical personnel to revise the conclusion draft as a final draft; and output the medical report format and the final draft as a medical report.

The medical report auxiliary generation system further includes a graphic display module, which performs the following tasks: marking the corresponding body part on the corresponding block of a human body organ graphic; Using the device and/or medicine, embed text, photos or representative images in or near the corresponding area of the selected body part, thereby generating an explanatory diagram of a medical report; and adding the explanatory diagram of the medical report to the medical report in the corresponding field of the report format.

The auxiliary generation system for medical reports also further includes a device data acquisition module, which is connected with a medical device signal to perform the following tasks: obtain a device data related to at least one treatment item from the medical device; and add the device data to in the corresponding field of the medical report format and in the narrative sentence.

Preferably, the medical device operates in conjunction with one of the means of use to obtain the device data.

Preferably, the medical report is an operation report, an examination report or a doctor's order report.

Preferably, the body part is tissue under a body organ.

Preferably, the treatment item is a specific surgical item, examination item or doctor's order.

Preferably, the first interface, the second interface and the third interface are presented as web pages through a network.

Using the historical data in the database module, the medical report generation module can generate relevant medical report drafts, so that medical personnel can reduce the occurrence of errors when writing medical reports. At the same time, the graphic display module of the present invention can automatically add explanatory diagrams to the medical report, and the equipment data obtaining module can also dynamically obtain the data of the external equipment and add it to the medical report for reference. The present invention effectively reduces the time cost that medical personnel spend on the medical report, and also increases the content of the medical report.

1: Operation terminal

2: Internet

3: Medical equipment

10: Servo host

110: Network communication interface

210: Personal Information Collection Module

220: List Mods

230:Database Module

240: Medical report generation module

250: Graphic Display Module

260: Device data acquisition module

FIG. 1 is a schematic structural diagram of a medical report auxiliary generation system according to an embodiment of the present invention, FIG. 2 is an example of a first interface, FIG. 3 is an example of a second interface, and FIG. 4 is a more complete Figure 5 shows the data structure of the database module, Figure 6 shows an example of a medical report format, Figure 7 shows an example of the third interface, and Figure 8 shows the final draft revised to final For an example of the third interface, Figure 9 shows an example of a medical report.

The present invention will be described more specifically by referring to the following embodiments.

Please refer to FIG. 1 , which is a schematic structural diagram of a medical report auxiliary generation system (hereinafter referred to as the system) according to an embodiment of the present invention. The system can be installed in a server host 10 and operates by the hardware structure of the server host 10 . The server host 10 may be one of the server clusters of the hospital information system, or may be hardware for providing hospital services by a third party, and the latter is not installed in one place with the server related to the hospital information system. The hardware structure of the server host 10 installed in the system is not much different from the general server structure, and may include a central processing unit, a memory, a storage device (such as a hard disk), an input/output unit, and the like. Although these hardwares are not shown in FIG. 1 , they are structures that should be understood by those skilled in the server field. In addition, one of the important hardware in the server host 10 is the network communication interface 110 , which is an important hardware and firmware (sometimes also includes programs running in the operating system) that connect the server host 10 and external hardware through the network 2 software), which can include network cards, connecting cables, wireless communication modules and other hardware. The following introduces the technical requirements of the present system for each module of the present invention to use or cooperate with the equipment of the above-mentioned existing server host 10 . Therefore, they can be software, including specific code and data, and run on at least a part of the hardware architecture under the operating system (for example, the code and related data files are stored in the storage device, in the operating system. It is temporarily stored in memory during operation, and is dynamically called and executed by the central processing unit). On the other hand, the modules may also be special hardware, such as application-specific integrated circuits (ASICs) or add-in cards, for performing the functions assigned by the modules. What's more, these technical elements can be partly software and partly hardware, and they are effectively integrated according to the needs of product designers, all within the technical scope claimed by this patent.

The system includes a data collection module 210 , a list listing module 220 , a database module 230 , a medical report generation module 240 , a graphic display module 250 and an equipment data acquisition module 260 . The personal data collection module 210 can obtain the basic personal data of the patient through a first interface provided on a manipulation terminal 1 . In this embodiment, the operating terminal 1 is a desktop computer, which is connected with the personal information collection module 210 through the network 2 and the network communication interface 110 . The operating terminal 1 can also be a notebook computer or a tablet computer, which is convenient for text editing operations. The personal information collection module 210 can present the first interface in the form of a web page (ie, a browser can acquire structural data without using other application software). An example of the first interface is shown in FIG. 2 . In the figure, the first interface is a part of a page, that is, the patient information area, but the first interface can occupy a single page or several related pages in other examples; It can be preset, or it can be copied and added according to requirements, so as to collect more detailed information. The second interface and the third interface mentioned below are the same. Through the first interface, medical personnel can input the patient's personal information, such as but not limited to name, gender, age, medical record number, examination number, bed number, family contact person, contact number, etc. Necessary personal information, such as name, gender and age, is necessary for the content of the medical report and can be collected at this stage to avoid copying and pasting when the report is written. The medical report in the present invention refers to an operation report, an inspection report and a doctor's order report. If the patient's personal information already exists in the hospital information system, the first interface can also be used to substitute some or all of the patient's personal information. It should be noted that the embodiments including the following descriptions are used to describe the functions of the system in the related operations of cardiology, but the present invention is not limited to use in cardiology. This system can also be applied to other medical departments after replacing the corresponding data and under the premise of meeting the specific needs of the department.

The list listing module 220 provides the medical staff to select body parts, treatment items, used devices and/or medicines related to the medical report, and the operation sequence of the treatment items through a second interface provided on the operating terminal 1 . An example of the second interface is shown in FIG. 3 . In this embodiment, the second interface also extends to include a part of the first interface in FIG. 2 . Human body parts refer to the tissues under the human organs that are mainly involved in medical reports. In cardiology, the parts of the human body can be the left coronary artery (LCA for short) and the right coronary artery (LCA). LCA can be further divided into left main trunk (LM for short), left circumflex branch (LCX for short) and left anterior descending branch (LAD for short) according to location. For health reports, the above distinction may be sufficient, but it is not clear enough for the surgical report to be issued by a cardiologist. A more complete description of the location of the cardiovascular body for the description of surgical results is shown in Figure 4. The complete description of the body part includes the anterior segment of the right coronary artery (RCA-p in English), the middle segment of the right coronary artery (RCA-m in English), the posterior segment of the right coronary artery (RCA-d in English), and the posterior descending branch of the right coronary artery (RCA-d). English abbreviation RCA-pda), right coronary posterior branch (English abbreviation RCA-pl), left circumflex anterior segment (English abbreviation LCX-p), left circumflex middle segment (English abbreviation LCX-m), left circumflex branch One obtuse marginal branch (LCX-om1), the second obtuse marginal branch of the left circumflex branch (LCX-om2), the third obtuse marginal branch of the left circumflex (LCX-om3), and the anterior segment of the left anterior descending branch (LCX-om3). LAD-p), middle left anterior descending branch (LAD-m), posterior left anterior descending branch (LAD-d), first diagonal branch of left anterior descending branch (LAD-d1) and left anterior descending branch Two diagonal branches (English abbreviation LAD-d2). The disposal items are specific surgical items, inspection items or doctor's orders, such as the operation items in Figure 2: Coronary Angiography (CAG for short), Left Ventricular Angiography (LVG for English), Great Artery Angiography (English for short) At least one of AOG), balloon catheter dilation (PTCA) and coronary stenting (STENT). In some embodiments, the treatment item may include more detailed techniques, for example, STENT may indicate that it is a technique using simple stenting, and the technique may also be selected in the second interface. The device used is a tool or large equipment that needs to be used during inspection or surgery. For example, the catheter (Catheter) can use different sizes of Medtronic model EBU; guide wire (English abbreviation GW) can use different sizes and styles of Terumo model Runthrough floppy; balloons (Balloon) can use different sizes of Medtronic model Sprinter; Stent can use different sizes of Abbott model Xience. Drugs are used in conjunction with disposal items, and can be selected independently or together with devices, the latter such as imaging agents, which will be used in CAG. The operation sequence of the treatment items is the sequence that the medical staff is expected to execute when there are more than one treatment items, which is shown by the dotted box in FIG. 3 .

The database module 230 stores the history records of the aforementioned combinations of body parts, treatment items, used devices and/or medicines, and operation sequences of treatment items (hereinafter referred to as operation combinations), wherein each combination corresponds to a patient diagnosis result. The patient diagnosis result is the actual diagnosis result record under the operation combination. Please refer to FIG. 5 for the data structure of the database module 230 . The database module 230 is a relational database, and connects each operation combination and its related data contents in batches according to the serial number sequence. For example, under item No. 15643, in addition to LAD-p (body parts), STENT/simple stenting (treatment items), Sprinter 2.5*20..., Xience 3.0*23... (use of devices and/or drugs), 1 LAD-p (operation sequence of disposal items), CAD with SVD, LAD-p with 70% stenosis (diagnosis result record), together with other optional data fields in the report, such as date, operator, etc., all together Bindings are established in related entries.

The medical report generation module 240 is an important technical element of the present invention and performs several tasks. The first task is to fill in the corresponding fields with the data from the first interface and the second interface through a medical report format. The medical report format is a unified format for medical reports. See Figure 6, which presents an example of a medical report format. In the upper Chinese part of the medical report format, the next field is filled with the information of the first interface, that is, patient information (personal data). The data in the right column of Final Diagnosis (final diagnosis), Operation, Procedure (program), Result (result) and Procedure note (program description) are the data from the second interface. The program description is a text description, and its editing method will be explained below. Signature is where the report maker and the operator sign. The second task of the medical report generation module 240 is to organize the corresponding body parts and the used devices and/or drugs into a narrative sentence according to the operation sequence of the treatment items, and list the corresponding patient diagnosis results in the database module 230 into a list. At the end of the narrative sentence to form a conclusion draft. Assuming a new anterior left circumflex stent procedure with the same body parts and use of devices and/or medications as the historical data No. 15643 in Figure 5, this combination of operations was cited to make the narrative. An example of this narrative sentence is "For LAD-p by stenting, POBA was performed with Sprinter 2.5*20 up to 12 atm, and stenting with Xience 3.0*23 up to 12 atm. Diagnosis: CAD with SVD, LAD-p with 70% stenosis." In organizing the aforementioned narrative sentences, different sentence templates can be used, but this example is not limited. The formatted paragraphs of these sentences are also stored in the database in the form of sentence templates. In the module 230. The third task of the medical report generation module 240 is to review and adjust the data in the fields through a third interface provided in the operation terminal 1, and to allow the medical staff to revise the draft of the conclusion as a final draft. An example of the three interfaces is shown in Figure 7. The Default page presents the final draft, which provides the medical staff with the pre-set conclusion draft. The medical staff can modify it in the program description field and set it as the final draft. Since the conclusion draft also contains Other pages such as personal information, final diagnosis, etc., these data can be modified in Revised Version (revised version). Please see Figure 8, which shows an example of the third interface where the final draft is revised to the final version. In the final version, the medical staff added The judgment statement of "The final result was optimal." was confirmed, and the diagnosis of stenosis was raised from 70% to 80%. It should be noted that, like the first interface and the second interface, the third interface is a web page through the Internet. In practice, the three can also be optimized and presented through an application program installed on the operating terminal 1. After the modification operation is completed, the medical report generation module 240 will output the medical report format and the final version as formal A medical report. An example of a medical report is shown in Figure 9. All relevant information is generated by the medical report generation module 240. It should be noted that the Image in the result shows the relevant position of the operation and its final diagnosis As a result, it is a visual presentation, which not only allows the viewer of the report to intuitively understand the patient's condition, but also helps the medical staff who wrote the report to reconfirm the patient's condition, so as to avoid errors in the report. The generation and modification of the image is performed by the graphical display model. The processing by group 250 is described below.

Graphics display module 250 performs several tasks. First, the graphic display module 250 marks the corresponding body part on the corresponding block of a human body organ graphic. Please refer to Figure 4 again. As far as cardiology is concerned, the graphic of human organs is the heart, especially all cardiovascular parts, that is, parts of the human body. Each body part corresponds to a name, such as LAD-p. Next, the graphic display module 250 embeds the corresponding treatment items and the use device and/or medicine of the body part selected in the second interface into the corresponding block of the selected body part with text, photos or representative images or near it, and then generate a medical report explanatory diagram. see FIG. 9 , the image diagram in the diagram is an example of an explanatory diagram of a medical report. In this embodiment, a text description is added near the cardiovascular blood vessel LAD-p, and is embedded in its vicinity. At the same time, the corresponding positions are also painted with shadows to express. Finally, the graphic display module 250 adds the explanatory diagram of the medical report to the corresponding field of the medical report format to complete the image part of the report.

Please refer to FIG. 1 , the device data acquisition module 260 is connected with a medical device 3 through a line signal to perform its work. Here, the line can be connected through the Internet, a mobile communication system or a fixed network system, it can also be a local area network in the hospital, or even a “dedicated line” specially set up for the medical equipment 3 . In this embodiment, the medical equipment 3 is a two-way X-ray machine for cardiac catheterization. In addition, the device data obtaining module 260 obtains a device data related to at least one treatment item from the medical device 3, such as an image position, and adds the device data to the corresponding fields and descriptive sentences of the medical report format. In other embodiments, the medical device 3 can be operated in conjunction with one of the use devices to obtain the device data, such as a cardiac catheter bidirectional X-ray machine in conjunction with a balloon to obtain the current position.

Although the present invention has been disclosed in the above embodiments, it is not intended to limit the present invention. Anyone with ordinary knowledge in the technical field can make some changes and modifications without departing from the spirit and scope of the present invention. Therefore, The protection scope of the present invention shall be determined by the scope of the appended patent application.

1: Operation terminal

2: Internet

3: Medical equipment

10: Servo host

110: Network communication interface

210: Personal Information Collection Module

220: List Mods

230:Database Module

240: Medical report generation module

250: Graphic Display Module

260: Device data acquisition module

Claims (8)

An auxiliary generating system for medical reports, installed in a server host, comprising: a data collection module, which obtains the patient's personal basic information through a first interface provided on an operating terminal; a list listing module, which provides medical personnel to select body parts, treatment items, used devices and/or medicines related to the medical report, and the operation sequence of treatment items through a second interface provided on the operating terminal; a database module that stores historical records of combinations of body parts, treatment items, used devices and/or drugs, and sequence of operation of treatment items, wherein each combination corresponds to a patient diagnosis result; and A medical report generation module that performs the following tasks: Through a medical report format, fill in the data from the first interface and the second interface into the corresponding fields; organize the corresponding body parts and use devices and/or drugs into a narrative sentence according to the operation sequence of the treatment items, and put the The corresponding patient diagnosis results in the database module are listed at the end of the narrative sentence to form a conclusion draft; Review and adjust the information in the fields through a third interface provided on the operating terminal, and allow the medical staff to revise the draft of the conclusion into a final draft; and Output the medical report format and the final version as a medical report. The auxiliary generation system for medical reports as described in claim 1, further comprising a graphic display module, which performs the following tasks: Mark the corresponding body part on the corresponding block of a human body organ graphic; The corresponding treatment items and use devices and/or medicines of the human body part selected in the second interface are embedded in or near the corresponding block of the selected human body part with text, photos or representative images, thereby generating a An explanatory diagram of a medical report; and Add the explanatory diagram of the medical report to the corresponding field of the medical report format. The auxiliary medical report generation system according to claim 1, further comprising a device data acquisition module, connected with a medical device signal, to perform the following tasks: obtain from the medical device a device data related to at least one treatment item; and The device data is added to the corresponding field of the medical report format and the narrative sentence. The auxiliary medical report generation system of claim 3, wherein the medical device operates in conjunction with one of the use devices to obtain the device data. The auxiliary medical report generation system according to claim 1, wherein the medical report is an operation report, an examination report or a doctor's order report. The auxiliary medical report generation system according to claim 1, wherein the human body part is a tissue under a human organ. The auxiliary medical report generation system according to claim 1, wherein the treatment item is a specific surgical item, an inspection item or a doctor's order. The auxiliary medical report generation system as claimed in claim 1, wherein the first interface, the second interface and the third interface are presented as web pages through a network.

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