WO2019084864A1

WO2019084864A1 - Method and apparatus for evaluating electronic medical record

Info

Publication number: WO2019084864A1
Application number: PCT/CN2017/109098
Authority: WO
Inventors: 刘莉; 罗常进; 蒋太鹏; 陈斌
Original assignee: 刘莉
Priority date: 2017-11-02
Filing date: 2017-11-02
Publication date: 2019-05-09

Abstract

A method for evaluating an electronic medical record, comprising: obtaining a selected electronic medical record and using same as a target medical record; obtaining at least one attribute item of the target medical record; displaying, on a preset medical record display interface, the obtained at least one attribute item and a corresponding attribute value evaluation assembly, the attribute value evaluation assembly comprising at least one evaluation tag; determining an evaluation tag selected by a user by means of the displayed attribute value evaluation assembly as a target evaluation tag; determining a corresponding attribute item evaluation score according to a preset correspondence relationship between an evaluation tag and an evaluation score as well as the target evaluation tag; calculating a total score value corresponding to the target medical record according to a preset medical record evaluation algorithm and the attribute item evaluation score corresponding to at least one attribute item; and displaying the total score value on the preset medical record display interface. The evaluation method can evaluate an electronic medical record in operation, and improves the accuracy of medical record evaluation compared with the prior art.

Description

Method and device for evaluating electronic medical record

Technical field

The invention relates to the technical field of medical and electronic medical records, and in particular to a method and a device for evaluating electronic medical records.

Background technique

The traditional hospital-level medical record quality control is mainly the quality control of the terminal medical records, that is, the spot check of the medical records that have been filed or the key departments of the key diseases are examined, and the medical records or punishments are revised after the problems are discovered. It is helpful to improve the quality of medical records, but because it only checks the medical records that have been filed, the quality of medical records filled during the hospitalization of patients cannot be well monitored, which leads to the emergence of medical treatment during hospitalization, surgery, etc. In the case of disputes, the quality of the sealed medical records cannot be guaranteed, which is not conducive to reducing the unfavorable factors in medical disputes, and is not conducive to promoting medical quality and patient safety. In other words, the quality of the running medical records needs to be checked.

The operation of the medical record quality control refers to the advancement of the medical record to the hospitalization period, and is synchronized with the clinician's diagnosis and treatment process, that is, from the patient's admission to the hospital, completed at the time of discharge, and can check and control the medical records at any time during the hospitalization of the patient. So that you can really improve the quality of medical records and the accuracy of medical data. Moreover, with the improvement of information systems and the popularity of computer management systems, electronic medical records have gradually replaced paper medical records. Most hospitals have adopted electronic medical records, which allows relevant departments to view the medical records of all patients in real time; The development of electronic medical record quality control system has begun when the electronic medical record is used, but it is limited to the time of medical record completion, project quality control, logical quality control, etc. The quality control of medical records is not realized by computer systems, so the current electronic The medical record quality control is still in accordance with the traditional manual inspection method for quality control of the terminal medical records. It is necessary to invest a large amount of manpower to check the running medical records, and in the traditional medical record checking method, it is artificially manual as a whole. The medical record is checked to determine whether there are some missing or imperfect places in the medical record, and finally a score is given as a whole, that is, for the same medical record, the evaluation score of the medical record will also exist because of the different personnel who perform the examination. different.

That is to say, in the related technical solution, the evaluation of the electronic medical record exists because of the artificial scoring The problem of low accuracy is not applicable to electronic medical record management systems.

Summary of the invention

Based on this, in the present invention, an evaluation method of an electronic medical record is proposed, which can evaluate an operational medical record of an electronic medical record state, and improve the accuracy of evaluation of a medical record.

An evaluation method for an electronic medical record, comprising:

Obtaining the selected electronic medical record as the target medical record, acquiring at least one attribute item of the target medical record, where each attribute item includes an attribute value corresponding to the attribute item;

Displaying, on the preset medical record display interface, the acquired at least one attribute item and an attribute value evaluation component corresponding to the attribute item, where the attribute value evaluation component includes at least one evaluation label;

Determining, by the user, the evaluation label selected by the attribute value evaluation component of the display as the target evaluation label corresponding to the attribute item, the number of the target evaluation label is at least one; according to the preset evaluation label and the evaluation score Corresponding relationship and the determined target evaluation label, determining an attribute item evaluation score corresponding to the attribute item;

Calculating a score according to a preset medical record evaluation algorithm and an attribute item corresponding to the at least one attribute item, calculating a total evaluation score corresponding to the target medical record, and displaying the total evaluation on the preset medical record display interface Score.

Optionally, in one embodiment, after the acquiring at least one attribute item of the target medical record, the method further includes:

Traversing the at least one attribute item, obtaining a preset attribute value filling rule corresponding to the attribute item for the attribute item traversed, and filling the rule according to the obtained attribute value and the attribute value corresponding to the attribute item, and calculating The attribute item corresponding to the attribute item evaluates the score;

Performing the calculation according to the preset medical record evaluation algorithm and the attribute item evaluation score corresponding to the at least one attribute item to calculate a total evaluation score corresponding to the target medical record.

Optionally, in one embodiment, the displaying, by the preset medical record display interface, the acquired at least one attribute item and the attribute value evaluation component corresponding to the attribute item further includes:

Determining, for each attribute item, a tag list corresponding to the attribute item, the tag list including a preset at least one evaluation tag;

Displaying the acquired at least one attribute item and the pair on the preset medical record display interface The attribute value evaluation component should also include:

And generating, according to the determined tag list, an attribute value evaluation component corresponding to the attribute item, where the attribute value evaluation component includes the preset at least one evaluation tag;

The attribute item and the corresponding attribute value evaluation component are displayed on the preset medical record display interface.

Optionally, in one embodiment, the calculating the score value according to the preset medical record evaluation algorithm and the attribute item corresponding to the at least one attribute item to calculate the total evaluation score corresponding to the target medical record further includes:

Obtaining a preset weight coefficient corresponding to each attribute item as a target weight coefficient;

And calculating a total evaluation score corresponding to the target medical record according to the attribute item evaluation score corresponding to the at least one attribute item and the target weight coefficient.

Optionally, in one embodiment, the calculating, according to the preset medical record evaluation algorithm and the attribute item evaluation score corresponding to the at least one attribute item, the total evaluation score corresponding to the target medical record further includes:

Determining whether the total evaluation score is less than a preset score threshold, and acquiring the determined target evaluation label if the total evaluation score is less than the preset score threshold;

The target medical record is marked according to the acquired target evaluation tag, and the target medical record is marked as a problem medical record.

Further, in the present embodiment, an evaluation apparatus for an electronic medical record is also proposed.

An evaluation device for an electronic medical record, comprising:

a medical record determining module, configured to acquire the selected electronic medical record as the target medical record, and acquire at least one attribute item of the target medical record, where each attribute item includes an attribute value corresponding to the attribute item;

a medical record display module, configured to display the acquired at least one attribute item and an attribute value evaluation component corresponding to the attribute item on a preset medical record display interface, where the attribute value evaluation component includes at least one evaluation label;

The attribute item evaluation score determining module is configured to determine, by the user, the evaluation label selected by the attribute value evaluation component of the display as the target evaluation label corresponding to the attribute item, where the number of the target evaluation labels is at least one; Correspondence between the evaluation label and the evaluation score and the determined target An evaluation tag, determining an attribute item evaluation score corresponding to the attribute item;

a total evaluation score calculation module, configured to calculate a score according to a preset medical record evaluation algorithm and an attribute item corresponding to the at least one attribute item, and calculate a total evaluation score corresponding to the target medical record, and in the preset The total evaluation score is displayed on the medical record display interface.

Optionally, in one embodiment, the attribute item evaluation score determining module is further configured to traverse the at least one attribute item, and obtain, for the traversed attribute item, a preset attribute value corresponding to the attribute item. Filling in the rule, calculating the attribute item evaluation score corresponding to the attribute item according to the obtained attribute value filling rule and the attribute value corresponding to the attribute item; and calling the total evaluation point value calculation module.

Optionally, in an embodiment, the device further includes an attribute value evaluation component generating module, configured to determine, for each attribute item, a tag list corresponding to the attribute item, where the tag list includes at least a preset An evaluation label;

The medical record display module is further configured to generate, according to the determined tag list, an attribute value evaluation component corresponding to the attribute item, where the attribute value evaluation component includes the preset at least one evaluation tag; The attribute item and the corresponding attribute value evaluation component are displayed on the medical record display interface.

Optionally, in one embodiment, the total evaluation score calculation module is further configured to acquire a preset weight coefficient corresponding to each attribute item as a target weight coefficient; according to the at least one attribute item The attribute item evaluation score and the target weight coefficient calculate a total evaluation score corresponding to the target medical record.

Optionally, in an embodiment, the device further includes a problem medical record marking module, configured to determine whether the total evaluation score is less than a preset score threshold, where the total evaluation score is less than the preset In the case of a score threshold, the determined target evaluation tag is acquired; the target medical record is marked according to the acquired target evaluation tag, and the target medical record is marked as a problem medical record.

Implementation of the embodiments of the present invention will have the following beneficial effects:

After the above electronic medical record evaluation method and device are adopted, for the running electronic medical record, the user can check whether the attribute value corresponding to each attribute item of the displayed electronic medical record satisfies the rule through the corresponding case display interface. And, by displaying the attribute value evaluation component corresponding to the attribute item, selecting an evaluation label corresponding to the attribute value of the attribute item, wherein each of the evaluation labels has a preset corresponding score, and determining according to the score Each genus that has been evaluated The score corresponding to the sexual item; finally, the total score of the displayed electronic medical record is calculated and displayed by the preset electronic medical record evaluation algorithm and the score corresponding to each attribute item, which is the total evaluation score. That is to say, after the evaluation method and device for the electronic medical record in the present invention are adopted, the automatic evaluation of the electronic medical record can be realized by labeling each attribute item, and the accuracy and credibility of the electronic medical record evaluation can be improved. .

Further, as long as it is an electronic medical record that can be viewed, it can be evaluated, which makes it possible for the corresponding quality control personnel to operate the electronic medical record or the already filed terminal case at each stage of the patient's hospitalization. The evaluation was carried out to improve the scope of application of the evaluation method of the electronic medical record.

DRAWINGS

In order to more clearly illustrate the embodiments of the present invention or the technical solutions in the prior art, the drawings used in the embodiments or the description of the prior art will be briefly described below. Obviously, the drawings in the following description are only It is a certain embodiment of the present invention, and other drawings can be obtained from those skilled in the art without any creative work.

among them:

1 is a schematic flow chart of an evaluation method of an electronic medical record in an embodiment;

2 is a schematic diagram of a display page of an electronic medical record in one embodiment;

3 is a schematic diagram of a display page of an electronic medical record in one embodiment;

FIG. 4 is a schematic structural diagram of an apparatus for evaluating an electronic medical record in an embodiment; FIG.

FIG. 5 is a schematic structural diagram of a computer device for operating the evaluation method of the aforementioned electronic medical record in one embodiment.

Detailed ways

The technical solutions in the embodiments of the present invention are clearly and completely described in the following with reference to the accompanying drawings in the embodiments of the present invention. It is obvious that the described embodiments are only a part of the embodiments of the present invention, but not all embodiments. All other embodiments obtained by those skilled in the art based on the embodiments of the present invention without creative efforts are within the scope of the present invention.

In this embodiment, an evaluation method of an electronic medical record is proposed, and the implementation of the method may depend on A computer program executable on a computer system based on a von Neumann system, which may be an application for evaluating an electronic medical record based on an electronic medical record management system or an electronic medical record evaluation system. The computer system may be a terminal device such as a smart phone, a tablet computer, a personal computer or the like that runs the above computer program.

It should be noted that, in this embodiment, the electronic medical record in the evaluation method of the electronic medical record is a medical record filled in a corresponding system by a doctor or other medical staff during a patient's treatment or hospitalization, for example, when the patient is admitted to the hospital. The electronic medical record corresponding to the patient, and within the hospitalized time of the patient, the doctor can further fill in the medical record at any time according to the specific conditions of medication, surgery, and examination. That is to say, the electronic medical record can be evaluated at any stage of the patient's hospitalization, and in the case where the electronic medical record has been filed, the electronic medical record evaluation method given in the embodiment can also be filed. The electronic medical record is evaluated.

Specifically, as shown in FIG. 1, the above electronic medical record evaluation method includes the following steps S102-S108:

Step S102: Acquire the selected electronic medical record as the target medical record.

In this embodiment, the determination of the target medical record may be randomly selected by the system, that is, the system randomly randomly selects all electronic medical records to determine one or more electronic medical records for examination. Alternatively, in another embodiment, the user may also conditionally set a random selection of the target medical record, for example, selecting a medical record of a certain department, or selecting a medical record of a certain doctor, or selecting a medical record of a certain time period, or selecting The medical record of a certain time period, or the medical record at a certain stage; of course, it can also be the inspection of all medical records under one or more selection conditions. Alternatively, in another embodiment, the user may also manually select an electronic medical record to be inspected in the medical record list as the target medical record. Or alternatively, in one embodiment, it is also possible to check all of the electronic medical records in the list one by one.

Step S104: Acquire at least one attribute item of the target medical record, where each attribute item includes an attribute value corresponding to the attribute item.

When filling in the electronic medical record, the user fills in according to multiple forms of the electronic medical record. For example, the general electronic medical record includes at least basic information such as the patient's name, history of allergies, patient's subjective condition, physical examination, medical record, medical order, and medication record. When multiple form items are selected, the user fills in the corresponding form content according to the label of the form item, thereby completing the filling of the electronic medical record.

In this embodiment, a form item filled in by the user during the process of filling in the electronic medical record is the target. An attribute item of the medical record, the form content filled in by the user in the process of filling in the electronic medical record is the attribute value corresponding to the attribute item. For example, in the application scenario shown in FIG. 2, FIG. 2 shows an example of an electronic medical record, and the number L1 (L11, L12, L13) is an attribute item of an electronic medical record, number L2 (L21, L22, L23) is the attribute value corresponding to the attribute item indicated by L1.

Generally speaking, doctors or other medical staff fill out more than one form of electronic medical records, that is, electronic medical records generated according to the form content filled out by doctors and other medical staff include more than one attribute item, and Each attribute item also contains the corresponding attribute value (it is required that the attribute value can be 0 or empty).

Step S106: Display the acquired at least one attribute item and an attribute value evaluation component corresponding to the attribute item on a preset medical record display interface, where the attribute value evaluation component includes at least one evaluation label.

When the user evaluates the running electronic medical record or the electronic medical record that has been archived, it is necessary to view the corresponding electronic medical record in the corresponding electronic medical record display page of the corresponding electronic medical record management system or the electronic medical record evaluation system, that is, the user You can view the electronic medical records that need to be evaluated in the medical record display interface.

In this embodiment, at least one attribute item acquired in step S104 is displayed in a preset medical record display interface. It should be noted that when all the attribute items of the target medical record are displayed, the displayed information includes and The attribute item label corresponding to the attribute item (for example, the number L3 in FIG. 2), and the attribute value corresponding to the attribute item.

Further, in order to facilitate the operation of the medical record reviewer or the medical record evaluator in performing the medical record evaluation, when displaying each attribute item of the target medical record, the attribute value evaluation component corresponding to the attribute item is also displayed, for example, The preset attribute value evaluation component display area next to the attribute item label of the displayed attribute item or the display page corresponding to the display area of the attribute item, and the attribute value evaluation component that the user can input is displayed.

It should be noted that, in this embodiment, the attribute value evaluation component includes an evaluation tag that can be selected, and more than one evaluation tag can be selected.

In the application scenario shown in FIG. 3, the attribute value evaluation component is shown by the number L4, and the user can input the evaluation corresponding to the attribute value corresponding to the attribute item by the attribute value evaluation component. In a specific embodiment, as shown in FIG. 3, the attribute value evaluation component is a pull-down selection including a plurality of evaluation tags. Box selection, the user can select the evaluation label to be entered through the drop-down selection box.

Step S108: It is determined that the user selects the evaluation label selected by the attribute value evaluation component of the display as the target evaluation label corresponding to the attribute item, and the number of the target evaluation labels is at least one.

As described above, the user can select a preset evaluation label corresponding to the attribute value evaluation corresponding to the current attribute item by displaying the attribute value evaluation component. For example, for the “allergy history item”, the evaluation label may be “drug”. Allergies are not filled out, or "the history of allergies is not standardized".

It should be noted that, in this embodiment, for one attribute item, more than one evaluation label can be input, and specifically, it can be determined according to system settings, that is, an evaluation label that can be input can be set in the system in advance. The number can be at most one, and the number of evaluation labels that can be entered can be set to more than one.

Because different attribute items may have different filling problems, for example, the "allergic history" item may be different from the "patient's main medical history" item, so if the same evaluation label is used for all attribute items There is a problem that the accuracy of the evaluation label is not high. Therefore, different evaluation labels are set for different attribute items, thereby improving the accuracy of the electronic medical record evaluation.

Specifically, for the attribute item that needs to be displayed, a label list corresponding to the attribute item is determined, and the label list includes a preset at least one evaluation label. That is to say, in the correspondence between the preset attribute item and the evaluation tag, the evaluation tag or the evaluation tag list corresponding to the current attribute item is determined. Moreover, for an attribute item, the number of corresponding pre-set evaluation tags may be more than one. Then, the determined evaluation tag list or the evaluation tag generates an attribute value evaluation component corresponding to the corresponding attribute item, the generated attribute value evaluation component corresponds to the attribute item, and includes the plurality of evaluation tags determined above. Or include all the evaluation labels included in the above-identified evaluation label list. Then, when the target medical record and at least one attribute item of the target medical record are displayed, the attribute value evaluation component displayed is the attribute value evaluation component generated above.

For example, in the application scenario shown in FIG. 3, the user can display all the evaluation labels that can be selected by clicking the drop-down selection box shown by the number L5, and then select the evaluation label to be input from the evaluation label of the display as the current The target evaluation label corresponding to the attribute item.

It should be noted that, in this embodiment, for a certain attribute item, the corresponding target evaluation label may be empty. That is to say, the user can submit an evaluation of the current target medical record without selecting a target evaluation tag corresponding to the partial attribute item.

Step S110: Determine an attribute item evaluation score corresponding to the attribute item according to the correspondence between the preset evaluation label and the evaluation score and the determined target evaluation label.

For different evaluation labels, the corresponding medical records are filled in different levels and levels. For example, in the “patient's chief medical history” item, the questions corresponding to the evaluation label “no complaint history” and “main complaint description is unclear” are different. In the process of evaluating or scoring the electronic medical record, the contribution to the final evaluation result of the electronic evaluation will be different. Therefore, the evaluation scores corresponding to different evaluation labels are also different.

In the present embodiment, the correspondence relationship between each evaluation label and the evaluation score is set in advance, for example, the evaluation score corresponding to "drug allergy not filled" is "-2 points", and the evaluation corresponding to "no admission record" The score is "-25 points". In the case where the target evaluation tag is determined, the evaluation score corresponding to each of the target evaluation tags can be determined according to the correspondence between the predetermined evaluation tag and the evaluation score.

Then, according to all the target evaluation labels corresponding to the attribute items and the evaluation scores corresponding to each of the target evaluation labels, the attribute item evaluation score corresponding to the attribute item is determined. For example, for the specified attribute item, the sum of the evaluation scores corresponding to all the target evaluation labels corresponding to the attribute item, that is, the attribute item of the attribute item is evaluated as a score.

Step S112: Calculate the score according to the preset medical record evaluation algorithm and the attribute item corresponding to the at least one attribute item, and calculate a total evaluation score corresponding to the target medical record.

In the present embodiment, the calculation method of the total evaluation score of the electronic medical record is set in advance, for example, by calculating the sum of the attribute items of each attribute item and the total evaluation score of the corresponding electronic medical record, or by The preset total evaluation score calculation formula calculates the score of the attribute item of each attribute item as an independent variable, and calculates the total evaluation score of the corresponding electronic medical record.

In this embodiment, in the case that the target medical record is determined, the attribute value of each attribute item of the target medical record and the corresponding attribute item evaluation score, and the preset medical record evaluation algorithm can calculate the current target medical record. Corresponding total evaluation score.

For example, in a specific embodiment, the target medical record D-Target contains N attribute items A ₁ , A ₂ , . . . , A _N , and their corresponding attribute values are a ₁ , a ₂ , . . . , a _N , and The attribute item evaluation score corresponding to the attribute item A _i is x _i , and the total evaluation score S _target calculated with the target medical record D-Target can be calculated by the following formula (1), (2) or (3):

Where α _i XX is a weight coefficient corresponding to A _i , and K is a constant greater than 0 and less than 100.

Further, the total evaluation score corresponding to the target medical record according to the preset medical record evaluation algorithm and the attribute item evaluation score corresponding to the at least one attribute item is specifically: obtaining a preset corresponding to each attribute item The weight coefficient is used as the target weight coefficient; and the total evaluation score corresponding to the target medical record is calculated according to the attribute item evaluation score corresponding to the at least one attribute item and the target weight coefficient.

That is to say, the weight coefficient corresponding to each attribute item is different, and the contribution of different attribute items to the total evaluation score is different. For example, the weight coefficient corresponding to the “sickness record” is greater than the weight coefficient corresponding to “doctoral”. In this embodiment, the weight coefficient corresponding to each attribute item is set in advance. In this step, when calculating the total evaluation score of the target medical record, the weight coefficient corresponding to each attribute item and the corresponding attribute item are The attribute item evaluates the score to calculate the total evaluation score of the target medical record.

It should be noted that the calculation method of the total evaluation score of the target medical record is not limited to the above.

Step S114: Display the total evaluation score on the preset medical record display interface.

In this embodiment, after the user submits the evaluation of the target medical record, the corresponding total evaluation score may be calculated according to the user's selection, and the corresponding total evaluation score is displayed on the display interface of the current target medical record. Further, in the corresponding medical record list, the total evaluation score of each electronic medical record that has been evaluated may also be displayed.

Further, in this embodiment, after evaluating each electronic medical record, not only the total evaluation score of the corresponding electronic medical record needs to be displayed on the corresponding page, but also when the total evaluation score is too low, the reminder is needed.

Specifically, the foregoing according to a preset medical record evaluation algorithm and an attribute corresponding to at least one attribute item After the item evaluation score is calculated, the total evaluation score corresponding to the target medical record further includes: determining whether the total evaluation score is less than a preset score threshold, and the total evaluation score is smaller than the preset score threshold. And obtaining the determined target evaluation label; marking the target medical record according to the acquired target evaluation label, and marking the target medical record as a problem medical record.

If the total evaluation score is too low, there is a big problem in the filling of the electronic medical record. It should be revised or reminded by the corresponding department to punish, or corrected in the later medical record filling. Therefore, in this embodiment, after the total evaluation score of the target medical record is determined, it is also required to determine whether the calculated total evaluation score satisfies a preset score condition, for example, whether it is greater than or equal to a preset score threshold. Moreover, if the total evaluation score of the target medical record is less than the preset score threshold, the target medical record is determined to be the problem medical record, and the target medical record is marked as the problem medical record.

Further, in order to facilitate the user to view the problem existing in the problem medical record, or to count the related defects existing in all the problem medical records, in this embodiment, in addition to the electronic medical record that the total evaluation score does not satisfy the preset score condition After being marked as the problem medical record, the attribute item tag of the attribute item corresponding to the attribute item evaluation score is also marked as the tag of the problem medical record. Further, since the evaluation tag is a tag for evaluating a problem existing in one attribute item of the target medical record, that is, the target evaluation tag may indicate a problem of the target medical record, and therefore, in this embodiment, it is also required All target evaluation labels determined during the evaluation of the target medical record are also added to the label of the problem medical record.

It should be noted that, in this embodiment, the user can manually check and label each attribute item of the electronic medical record for a certain defect. However, the evaluation of the electronic medical record is not limited to the manual label of the user, and may also include Automatic evaluation of the computer.

For example, for an attribute item (required) that must be filled in the electronic medical record, if the relevant medical staff does not fill in the filling process, that is, if the required attribute value is blank, the electronic medical record relationship system or electronic medical record The evaluation system automatically detects whether the attribute value of the required item is empty, and evaluates the evaluation rule of the score according to the preset required item, and gives the corresponding attribute item evaluation score.

In another specific embodiment, not only can the attribute value be automatically detected, but also whether the attribute value of the attribute item satisfies a preset condition, for example, whether the “year of birth” is within a specified range. For example, whether the "medication note" contains the specified specification content, and, for example, whether the "surgical record" is filled in within 2 hours after the completion of the operation time.

Specifically, in an embodiment, after the step of acquiring at least one attribute item of the target medical record, The method further includes: traversing the at least one attribute item, obtaining a preset attribute value filling rule corresponding to the attribute item for the traversed attribute item, filling in the rule according to the obtained attribute value, and the attribute value corresponding to the attribute item And calculating an attribute item evaluation score corresponding to the attribute item; and calculating a total evaluation score corresponding to the target medical record according to the preset medical record evaluation algorithm and the attribute item evaluation score corresponding to the at least one attribute item.

That is to say, for each attribute item, the attribute value filling rule corresponding to the attribute item is determined, and the attribute value of the attribute item is evaluated according to the attribute value filling rule, and the corresponding attribute item evaluation score is calculated, The score can be used for the calculation of the final total evaluation score.

In addition, in order to solve the technical problem that the user is insufficiently reminded when there is a risk in the process of chatting between the user and other users through the instant messaging application or the social network platform in the conventional technology, in one embodiment, as shown in the figure As shown in Fig. 4, an evaluation device for an electronic medical record is also proposed, including:

The medical record determining module 102 is configured to obtain the selected electronic medical record as the target medical record, and acquire at least one attribute item of the target medical record, where each attribute item includes an attribute value corresponding to the attribute item;

The medical record display module 104 is configured to display the acquired at least one attribute item and an attribute value evaluation component corresponding to the attribute item on a preset medical record display interface, where the attribute value evaluation component includes at least one evaluation label;

The attribute item evaluation score determining module 106 is configured to determine, by the user, the evaluation label selected by the attribute value evaluation component of the display as the target evaluation label corresponding to the attribute item, where the number of the target evaluation labels is at least one; Determining a correspondence between the evaluation label and the evaluation score and the determined target evaluation label, and determining an attribute item evaluation score corresponding to the attribute item;

The total evaluation score calculation module 108 is configured to calculate a score according to a preset medical record evaluation algorithm and an attribute item corresponding to the at least one attribute item, and calculate a total evaluation score corresponding to the target medical record, and the preset The total evaluation score is displayed on the medical record display interface.

Optionally, in an embodiment, the attribute item evaluation score determining module 106 is further configured to traverse the at least one attribute item, and obtain, for the traversed attribute item, a preset attribute value filling rule corresponding to the attribute item. And calculating an attribute item evaluation score corresponding to the attribute item according to the obtained attribute value filling rule and the attribute value corresponding to the attribute item; and calling the total evaluation score calculation module 108.

Optionally, in an embodiment, as shown in FIG. 4, the foregoing apparatus further includes an attribute value evaluation component generating module 110, configured to determine, for each attribute item, a tag list corresponding to the attribute item, where the tag list is Include at least one evaluation label preset;

The medical record display module 104 is further configured to generate, according to the determined tag list, an attribute value evaluation component corresponding to the attribute item, where the attribute value evaluation component includes the preset at least one evaluation tag; The attribute item and the corresponding attribute value evaluation component are displayed on the medical record display interface.

Optionally, in an embodiment, the total evaluation score calculation module 108 is further configured to acquire a preset weight coefficient corresponding to each attribute item as a target weight coefficient; according to the attribute item corresponding to the at least one attribute item. The evaluation score and the target weight coefficient are calculated, and a total evaluation score corresponding to the target medical record is calculated.

Optionally, in an embodiment, as shown in FIG. 4, the apparatus further includes a problem medical record marking module 112, configured to determine whether the total evaluation score is less than a preset score threshold, and the total evaluation score is If the preset score threshold is smaller than the preset score threshold, the determined target evaluation label is acquired; the target medical record is marked according to the acquired target evaluation label, and the target medical record is marked as a problem medical record.

After the above electronic medical record evaluation method and device are adopted, for the running electronic medical record, the user can check whether the attribute value corresponding to each attribute item of the displayed electronic medical record satisfies the rule through the corresponding case display interface. And, by displaying the attribute value evaluation component corresponding to the attribute item, selecting an evaluation label corresponding to the attribute value of the attribute item, wherein each of the evaluation labels has a preset corresponding score, and determining according to the score Each of the scores corresponding to the evaluated attribute item; finally, the total score of the displayed electronic medical record is calculated and displayed by the preset electronic medical record evaluation algorithm and the score corresponding to each attribute item, that is, the total evaluation score . That is to say, after the evaluation method and device for the electronic medical record in the present invention are adopted, the automatic evaluation of the electronic medical record can be realized by labeling each attribute item, and the accuracy and credibility of the electronic medical record evaluation can be improved. .

Further, as long as it is an electronic medical record that can be viewed, it can be evaluated, which makes it possible for the corresponding quality control personnel to operate the electronic medical record at each stage of the patient's hospitalization or The final cases that have been filed are evaluated to improve the scope of application of the electronic medical record evaluation method.

In the above embodiments, it may be implemented in whole or in part by software, hardware, firmware, or any combination thereof. When implemented using a software program, it may be implemented in whole or in part in the form of a computer program product. The computer program product includes one or more computer instructions. When the computer program instructions are loaded and executed on a computer, the processes or functions described in accordance with embodiments of the present invention are generated in whole or in part. The computer can be a general purpose computer, a special purpose computer, a computer network, or other programmable device. The computer instructions can be stored in a computer readable storage medium or transferred from one computer readable storage medium to another computer readable storage medium, for example, the computer instructions can be from a website site, computer, server or data center Transfer to another website site, computer, server, or data center by wire (eg, coaxial cable, fiber optic, digital subscriber line (DSL), or wireless (eg, infrared, wireless, microwave, etc.). The computer readable storage medium can be any available media that can be accessed by a computer or a data storage device such as a server, data center, or the like that includes one or more available media. The usable medium may be a magnetic medium (eg, a floppy disk, a hard disk, a magnetic tape), an optical medium (eg, a DVD), or a semiconductor medium (such as a solid state disk (SSD)) or the like.

In one embodiment, as shown in FIG. 5, FIG. 5 illustrates a terminal of a von Neumann system-based computer system that operates the evaluation method of the electronic medical record described above. The computer system can be a terminal device such as a smartphone, a tablet, a palmtop, a laptop, or a personal computer. Specifically, an external input interface 1001, a processor 1002, a memory 1003, and an output interface 1004 connected through a system bus may be included. The external input interface 1001 can optionally include at least a network interface 10012. The memory 1003 may include an external memory 10032 (eg, a hard disk, an optical disk, or a floppy disk, etc.) and an internal memory 10034. The output interface 1004 can include at least a device such as a display 10042.

In this embodiment, the operation of the method is based on a computer program whose program file is stored in the external memory 10032 of the aforementioned von Neumann system-based computer system, loaded into the internal memory 10034 at runtime, and then After being compiled into machine code, it is passed to the processor 1002 for execution, thereby forming logically various modules in the von Neumann system-based computer system. And during the execution of the evaluation method of the electronic medical record, the input parameters are all passed through the external input interface 1001. The data is received and transferred to the memory 1003 for processing, and then input to the processor 1002 for processing. The processed result data is cached in the memory 1003 for subsequent processing, or is transmitted to the output interface 1004 for output.

The above is only the preferred embodiment of the present invention, and the scope of the present invention is not limited thereto, and thus equivalent changes made in the claims of the present invention are still within the scope of the present invention.

Claims

An evaluation method for an electronic medical record, comprising:

Obtaining the selected electronic medical record as the target medical record, acquiring at least one attribute item of the target medical record, where each attribute item includes an attribute value corresponding to the attribute item;

Displaying, on the preset medical record display interface, the acquired at least one attribute item and an attribute value evaluation component corresponding to the attribute item, where the attribute value evaluation component includes at least one evaluation label;

Determining, by the user, the evaluation label selected by the attribute value evaluation component of the display as the target evaluation label corresponding to the attribute item, the number of the target evaluation label is at least one; according to the preset evaluation label and the evaluation score Corresponding relationship and the determined target evaluation label, determining an attribute item evaluation score corresponding to the attribute item;

Calculating a score according to a preset medical record evaluation algorithm and an attribute item corresponding to the at least one attribute item, calculating a total evaluation score corresponding to the target medical record, and displaying the total evaluation on the preset medical record display interface Score.
The method for evaluating an electronic medical record according to claim 1, wherein the obtaining the at least one attribute item of the target medical record further comprises:

Traversing the at least one attribute item, obtaining a preset attribute value filling rule corresponding to the attribute item for the attribute item traversed, and filling the rule according to the obtained attribute value and the attribute value corresponding to the attribute item, and calculating The attribute item corresponding to the attribute item evaluates the score;

Performing the calculation according to the preset medical record evaluation algorithm and the attribute item evaluation score corresponding to the at least one attribute item to calculate a total evaluation score corresponding to the target medical record.
The method for evaluating an electronic medical record according to claim 1, wherein the displaying the at least one attribute item and the attribute value evaluation component corresponding to the attribute item before displaying the predetermined medical record display interface include:

Determining, for each attribute item, a tag list corresponding to the attribute item, the tag list including a preset at least one evaluation tag;

The displaying the at least one attribute item and the corresponding attribute value evaluation component on the preset medical record display interface further includes:

And generating, according to the determined tag list, an attribute value evaluation component corresponding to the attribute item, where the attribute value evaluation component includes the preset at least one evaluation tag;

The attribute item and the corresponding attribute value evaluation component are displayed on the preset medical record display interface.
The electronic medical record evaluation method according to claim 1, wherein the total evaluation score corresponding to the target medical record is calculated according to a preset medical record evaluation algorithm and an attribute item evaluation score corresponding to at least one attribute item. Values also include:

Obtaining a preset weight coefficient corresponding to each attribute item as a target weight coefficient;

And calculating a total evaluation score corresponding to the target medical record according to the attribute item evaluation score corresponding to the at least one attribute item and the target weight coefficient.
The electronic medical record evaluation method according to claim 1, wherein the total evaluation score corresponding to the target medical record is calculated according to a preset medical record evaluation algorithm and an attribute item evaluation score corresponding to at least one attribute item. After the value also includes:

Determining whether the total evaluation score is less than a preset score threshold, and acquiring the determined target evaluation label if the total evaluation score is less than the preset score threshold;

The target medical record is marked according to the acquired target evaluation tag, and the target medical record is marked as a problem medical record.
An evaluation device for an electronic medical record, comprising:

a medical record determining module, configured to acquire the selected electronic medical record as the target medical record, and acquire at least one attribute item of the target medical record, where each attribute item includes an attribute value corresponding to the attribute item;

a medical record display module, configured to display the acquired at least one attribute item and an attribute value evaluation component corresponding to the attribute item on a preset medical record display interface, where the attribute value evaluation component includes at least one evaluation label;

An attribute item evaluation score determining module, configured to determine a user evaluation component by using the attribute value of the display The selected evaluation label is used as the target evaluation label corresponding to the attribute item, and the number of the target evaluation labels is at least one; according to the correspondence between the preset evaluation label and the evaluation score and the determined target evaluation label, determining and The attribute item corresponding to the attribute item evaluates the score;

a total evaluation score calculation module, configured to calculate a score according to a preset medical record evaluation algorithm and an attribute item corresponding to the at least one attribute item, and calculate a total evaluation score corresponding to the target medical record, and in the preset The total evaluation score is displayed on the medical record display interface.
The apparatus for evaluating an electronic medical record according to claim 6, wherein the attribute item evaluation score determining module is further configured to traverse the at least one attribute item, and acquire the preset and the attribute item that is traversed The attribute value corresponding to the attribute item fills in a rule, and according to the obtained attribute value filling rule and the attribute value corresponding to the attribute item, the attribute item evaluation score corresponding to the attribute item is calculated; and the total evaluation score calculation module is invoked.
The device for evaluating an electronic medical record according to claim 6, wherein the device further comprises an attribute value evaluation component generating module, configured to determine, for each attribute item, a tag list corresponding to the attribute item, the tag The list includes at least one evaluation tag preset;

The medical record display module is further configured to generate, according to the determined tag list, an attribute value evaluation component corresponding to the attribute item, where the attribute value evaluation component includes the preset at least one evaluation tag; The attribute item and the corresponding attribute value evaluation component are displayed on the medical record display interface.
The apparatus for evaluating an electronic medical record according to claim 6, wherein the total evaluation score calculation module is further configured to acquire a preset weight coefficient corresponding to each attribute item as a target weight coefficient; The attribute item evaluation score corresponding to the at least one attribute item and the target weight coefficient, and the total evaluation score corresponding to the target medical record is calculated.
The apparatus for evaluating an electronic medical record according to claim 6, wherein the apparatus further comprises a problem medical record marking module, configured to determine whether the total evaluation score is less than a preset score threshold, in the total evaluation score If the value is less than the preset score threshold, acquiring the determined target evaluation label; marking the target medical record according to the acquired target evaluation label, and marking the target The medical record is marked as the problem medical record.