WO2019084864A1 - Method and apparatus for evaluating electronic medical record - Google Patents
Method and apparatus for evaluating electronic medical record Download PDFInfo
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- WO2019084864A1 WO2019084864A1 PCT/CN2017/109098 CN2017109098W WO2019084864A1 WO 2019084864 A1 WO2019084864 A1 WO 2019084864A1 CN 2017109098 W CN2017109098 W CN 2017109098W WO 2019084864 A1 WO2019084864 A1 WO 2019084864A1
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- G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H10/00—ICT specially adapted for the handling or processing of patient-related medical or healthcare data
- G16H10/60—ICT specially adapted for the handling or processing of patient-related medical or healthcare data for patient-specific data, e.g. for electronic patient records
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- 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.
- 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.
- an evaluation method of an electronic medical record 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;
- the evaluation label selected by the attribute value evaluation component of the display 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;
- the method further includes:
- 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:
- the attribute value evaluation component should also include:
- the attribute item and the corresponding attribute value evaluation component are displayed on the preset medical record display interface.
- 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:
- 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:
- 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 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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. .
- 1 is a schematic flow chart of an evaluation method of an electronic medical record in an embodiment
- FIG. 2 is a schematic diagram of a display page of an electronic medical record in one embodiment
- FIG. 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. 5 is a schematic structural diagram of a computer device for operating the evaluation method of the aforementioned electronic medical record in one 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- the user fills in according to multiple forms of the electronic medical record.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- the attribute value evaluation component includes an evaluation tag that can be selected, and more than one evaluation tag can be selected.
- 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.
- 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.
- 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.
- the evaluation label may be “drug”. Allergies are not filled out, or "the history of allergies is not standardized”.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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".
- 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.
- 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.
- 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.
- 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.
- 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
- 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):
- ⁇ i XX is a weight coefficient corresponding to A i
- K is a constant greater than 0 and less than 100.
- 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.
- the weight coefficient corresponding to each attribute item is different, and the contribution of different attribute items to the total evaluation score is different.
- the weight coefficient corresponding to the “sickness record” is greater than the weight coefficient corresponding to “doctoral”.
- 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.
- 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.
- 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.
- 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.
- 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.
- a preset score condition for example, whether it is greater than or equal to a preset score threshold.
- 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.
- 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.
- the user can manually check and label each attribute item of the electronic medical record for a certain defect.
- 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.
- the electronic medical record relationship system or electronic medical record 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.
- the attribute value 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.
- 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.
- 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.
- an evaluation device for an electronic medical record 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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. .
- the above embodiments it may be implemented in whole or in part by software, hardware, firmware, or any combination thereof.
- 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.
- the computer program 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.
- a magnetic medium eg, a floppy disk, a hard disk, a magnetic tape
- an optical medium eg, a DVD
- a semiconductor medium such as a solid state disk (SSD)
- 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.
- 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.
- 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.
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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
本发明涉及医学和电子病历技术领域,尤其涉及一种电子病历的评价方法及装置。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.
传统的医院院级病历质控主要是终末病历质控,即对已经归档的病历进行抽查或者重点病种重点科室进行检查,在发现问题之后再修改病历或者处罚,这种时候检查的方法虽然对病历质量的提高有帮助,但因为只是针对已经归档的病历进行检查,对于患者住院期间的病历填写质量并不能进行很好的监控,这就导致了在病人住院、手术等过程中出现了医疗纠纷时,封存的病历的质量无法得到保证,不利于减少医疗纠纷中的不利因素,也不利于促进医疗质量与患者安全。也就是说,需要对运行病历的质量进行检查。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.
运行病历质控是指在将对病历的检查提前到住院期间,并且与临床医生的诊疗过程同步,即从患者入院开始,出院时完成,可以针对患者住院的任意时段的病历进行检查和质控,从而可以真正的提高病历的质量以及医疗数据的精准度。并且,随着信息系统的完善和计算机管理系统的普及,电子病历逐渐取代了纸质的病历,绝大多数医院均采用了电子病历,这就使得相关的科室可以实时的查看所有病人的病历;电子病历质控系统的研发,在电子病历使用时就已经开始了,但仅限于病历完成的时间、项目质控、逻辑质控等,病历内涵质控是计算机系统还无法实现的,因此目前电子病历质控仍然按照传统的对终末病历进行质控的人工检查的方法,需要投入大量的人力对运行病历进行检查,并且,在传统的病历检查方法中,是人为的手动的从整体上对病历进行检查,确定病历是否存在某些缺漏或者不完善的地方,最后从整体上给出一个分数,也就是说,对于同一份病历,因为进行检查的人员的不同对病历的评价分数也会存在不同。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.
也就是说,在相关技术方案中,对于电子病历的评价因为人工的打分存在
准确度不高的问题,且不适用于电子病历管理系统。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.
发明内容Summary of the invention
基于此,在本发明中,特提出了一种电子病历的评价方法,可对电子病历状态的运行病历进行评价,并且,提高了对于病历的评价的准确度。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.
一种电子病历的评价方法,包括:An evaluation method for an electronic medical record, comprising:
获取选择的电子病历作为目标病历,获取所述目标病历的至少一个属性项,所述每一个属性项包括与该属性项对应的的属性值;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;
在预设的病历展示界面上展示所述获取到的至少一个属性项以及与该属性项对应的属性值评价组件,所述属性值评价组件包括至少一个评价标签;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;
确定用户通过所述展示的属性值评价组件选择的评价标签作为与该属性项对应的目标评价标签,所述目标评价标签的数量至少为一;根据预设的评价标签与评价分值之间的对应关系以及确定的目标评价标签,确定与该属性项对应的属性项评价分值;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;
根据预设的病历评价算法以及与至少一个属性项对应的属性项评价分值,计算与所述目标病历对应的总评价分值,并在所述预设的病历展示界面上展示所述总评价分值。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.
可选的,在其中一个实施例中,所述获取所述目标病历的至少一个属性项之后还包括:Optionally, in one embodiment, after the acquiring at least one attribute item of the target medical record, the method further includes:
遍历所述至少一个属性项,对于遍历到的属性项,获取预设的与该属性项对应的属性值填写规则,根据获取到的属性值填写规则以及与该属性项对应的属性值,计算与该属性项对应的属性项评价分值;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;
执行所述根据预设的病历评价算法以及与至少一个属性项对应的属性项评价分值计算与所述目标病历对应的总评价分值。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.
可选的,在其中一个实施例中,所述在预设的病历展示界面上展示所述获取到的至少一个属性项以及与该属性项对应的属性值评价组件之前还包括: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:
对于每一个属性项,确定与该属性项对应的标签列表,所述标签列表包括预设的至少一个评价标签;Determining, for each attribute item, a tag list corresponding to the attribute item, the tag list including a preset at least one evaluation tag;
所述在预设的病历展示界面上展示所述获取到的至少一个属性项以及对
应的属性值评价组件还包括: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:
根据所述确定的标签列表生成与该属性项对应的属性值评价组件,所述属性值评价组件包含所述预设的至少一个评价标签;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;
在所述预设的病历展示界面上展示所述属性项以及对应的属性值评价组件。The attribute item and the corresponding attribute value evaluation component are displayed on the preset medical record display interface.
可选的,在其中一个实施例中,所述根据预设的病历评价算法以及与至少一个属性项对应的属性项评价分值计算与所述目标病历对应的总评价分值还包括: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:
获取预设的与每一个属性项对应的权重系数作为目标权重系数;Obtaining a preset weight coefficient corresponding to each attribute item as a target weight coefficient;
根据所述与至少一个属性项对应的属性项评价分值以及所述目标权重系数,计算与所述目标病历对应的总评价分值。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.
可选的,在其中一个实施例中,所述根据预设的病历评价算法以及与至少一个属性项对应的属性项评价分值计算与所述目标病历对应的总评价分值之后还包括: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:
判断所述总评价分值是否小于预设的分数阈值,在所述总评价分值小于所述预设的分数阈值的情况下,获取所述确定的目标评价标签;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;
根据所述获取的目标评价标签对所述目标病历进行标记,并将所述目标病历标记为问题病历。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.
此外,在本实施例中,还提出了一种电子病历的评价装置。Further, in the present embodiment, an evaluation apparatus for an electronic medical record is also proposed.
一种电子病历的评价装置,包括:An evaluation device for an electronic medical record, comprising:
病历确定模块,用于获取选择的电子病历作为目标病历,获取所述目标病历的至少一个属性项,所述每一个属性项包括与该属性项对应的的属性值;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;
病历展示模块,用于在预设的病历展示界面上展示所述获取到的至少一个属性项以及与该属性项对应的属性值评价组件,所述属性值评价组件包括至少一个评价标签;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;
属性项评价分值确定模块,用于确定用户通过所述展示的属性值评价组件选择的评价标签作为与该属性项对应的目标评价标签,所述目标评价标签的数量至少为一;根据预设的评价标签与评价分值之间的对应关系以及确定的目标
评价标签,确定与该属性项对应的属性项评价分值;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;
总评价分值计算模块,用于根据预设的病历评价算法以及与至少一个属性项对应的属性项评价分值,计算与所述目标病历对应的总评价分值,并在所述预设的病历展示界面上展示所述总评价分值。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.
可选的,在其中一个实施例中,所述属性项评价分值确定模块还用于遍历所述至少一个属性项,对于遍历到的属性项,获取预设的与该属性项对应的属性值填写规则,根据获取到的属性值填写规则以及与该属性项对应的属性值,计算与该属性项对应的属性项评价分值;调用所述总评价分值计算模块。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.
可选的,在其中一个实施例中,所述装置还包括属性值评价组件生成模块,用于对于每一个属性项,确定与该属性项对应的标签列表,所述标签列表包括预设的至少一个评价标签;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;
所述病历展示模块还用于根据所述确定的标签列表生成与该属性项对应的属性值评价组件,所述属性值评价组件包含所述预设的至少一个评价标签;在所述预设的病历展示界面上展示所述属性项以及对应的属性值评价组件。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.
可选的,在其中一个实施例中,所述总评价分值计算模块还用于获取预设的与每一个属性项对应的权重系数作为目标权重系数;根据所述与至少一个属性项对应的属性项评价分值以及所述目标权重系数,计算与所述目标病历对应的总评价分值。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.
可选的,在其中一个实施例中,所述装置还包括问题病历标记模块,用于判断所述总评价分值是否小于预设的分数阈值,在所述总评价分值小于所述预设的分数阈值的情况下,获取所述确定的目标评价标签;根据所述获取的目标评价标签对所述目标病历进行标记,并将所述目标病历标记为问题病历。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.
实施本发明实施例,将具有如下有益效果:Implementation of the embodiments of the present invention will have the following beneficial effects:
采用了上述电子病历的评价方法和装置之后,对于运行中的电子病历,用户可以通过相应的病例展示界面,对展示的电子病历的每一个属性项对应的属性值的填写是否满足规则进行检查,并且,通过展示的与该属性项对应的属性值评价组件来选择对于该属性项的属性值对应的评价标签,其中每一个评价标签都存在一个预设的对应的评分,根据该评分即可确定每一个进行评价了的属
性项对应的评分;最后,通过预设的电子病历评价算法、以及每一个属性项对应的评分,计算展示的电子病历的总评分并进行展示,即为总评价分值。也就是说,采用了本发明中的电子病历的评价方法和装置之后,可以通过对每一个属性项进行标签的方法来实现对电子病历的自动评价,提高电子病历评价的准确度和可信度。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. .
进一步的,只要是可以进行查看的电子病历均可以对其进行评价,这就使得在病人住院的每一个阶段,相应的质控人员等均可以对运行中的电子病历或者已经归档的终末病例进行评价,提高了电子病历的评价方法的适用范围。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.
为了更清楚地说明本发明实施例或现有技术中的技术方案,下面将对实施例或现有技术描述中所需要使用的附图作简单地介绍,显而易见地,下面描述中的附图仅仅是本发明的一些实施例,对于本领域普通技术人员来讲,在不付出创造性劳动的前提下,还可以根据这些附图获得其他的附图。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.
其中:among them:
图1为一个实施例中一种电子病历的评价方法的流程示意图;1 is a schematic flow chart of an evaluation method of an electronic medical record in an embodiment;
图2为一个实施例中电子病历的展示页面的示意图;2 is a schematic diagram of a display page of an electronic medical record in one embodiment;
图3为一个实施例中电子病历的展示页面的示意图;3 is a schematic diagram of a display page of an electronic medical record in one embodiment;
图4为一个实施例中一种电子病历的评价装置的结构示意图;FIG. 4 is a schematic structural diagram of an apparatus for evaluating an electronic medical record in an embodiment; FIG.
图5为一个实施例中运行前述电子病历的评价方法的计算机设备的结构示意图。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.
下面将结合本发明实施例中的附图,对本发明实施例中的技术方案进行清楚、完整地描述,显然,所描述的实施例仅仅是本发明一部分实施例,而不是全部的实施例。基于本发明中的实施例,本领域普通技术人员在没有作出创造性劳动前提下所获得的所有其他实施例,都属于本发明保护的范围。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.
在本实施例中,提出了一种电子病历的评价方法,该方法的实现可依赖于
计算机程序,该计算机程序可运行于基于冯诺依曼体系的计算机系统之上,该计算机程序可以是基于电子病历管理系统或电子病历评价系统的对电子病历进行评价的应用程序。该计算机系统可以是运行上述计算机程序的例如智能手机、平板电脑、个人电脑等终端设备。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.
需要说明的是,在本实施例中,上述电子病历的评价方法中的电子病历是在病人治病或住院期间医生或者其他医护人员在相应的系统中填写的病历,例如,在病人入院时建立与该病人对应的电子病历,并且,在该病人的住院时间之内,医生可以随时根据用药、手术、检查的具体情况进一步的填写病历。也就是说,在病人住院期间的任何阶段,均可以对电子病历进行评价,并且,在电子病历已经归档的情况下,也可以通过本实施例中给出的电子病历的评价方法对该已经归档的电子病历进行评价。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.
具体的,如图1所示,上述电子病历的评价方法包括如下步骤S102-S108:Specifically, as shown in FIG. 1, the above electronic medical record evaluation method includes the following steps S102-S108:
步骤S102:获取选择的电子病历作为目标病历。Step S102: Acquire the selected electronic medical record as the target medical record.
在本实施例中,目标病历的确定可以是系统随机进行选择的,也就是说,系统随机对所有的电子病历进行随机筛选,确定一个或多个电子病历进行检查。或者,在另一个实施例中,用户还可以对目标病历的随机选择进行条件设置,例如,选择某一个科室的病历、或者选择某一个医生的病历、或者选择某一个时间阶段的病历、或者选择某一个时间段的病历、或者选择处于某一个阶段的病历;当然也可以是某一个或多个选择条件下的所有的病历进行检查。或者,在另一个实施例中,用户还可以手动在病历列表中选择需要进行检查的电子病历作为目标病历。又或者,在一个实施例中,还可以是对列表中的所有的电子病历逐个进行检查。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.
步骤S104:获取所述目标病历的至少一个属性项,所述每一个属性项包括与该属性项对应的的属性值。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.
用户在填写电子病历时,会按照电子病历的多个表单进行填写,例如,一般的电子病历至少包括病人姓名等基本信息、过敏史、病人主述病情、体格检查、病程记录、医嘱、用药记录等多个表单项,用户会根据表单项的标签填写对应的表单内容,从而完成电子病历的填写。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.
在本实施例中,用户在填写电子病历的过程中填写的一个表单项即为目标
病历的一个属性项,用户在填写电子病历的过程中填写的表单内容即为该属性项对应的属性值。例如,在图2所示的应用场景中,图2展示了一个电子病历的示例,编号L1(L11、L12、L13)所示即为一个电子病历的一个属性项,编号L2(L21、L22、L23)所示即为L1所示的属性项对应的属性值。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.
一般来讲,医生或其他医护人员填写的电子病历中需要填写的表单项不止一项,也就是说,根据医生和其他医护人员填写的表单内容生成的电子病历包括了不止一个属性项,并且,每一个属性项还包含了对应的属性值(需要说明的是,属性值可以为0或者空)。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).
步骤S106:在预设的病历展示界面上展示所述获取到的至少一个属性项以及与该属性项对应的属性值评价组件,所述属性值评价组件包括至少一个评价标签。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.
在用户对运行中的电子病历或者已经归档的电子病历进行评价时,需要在相应的电子病历管理系统或者电子病历评价系统中对应的电子病历展示页面中查看相应的电子病历,也就是说,用户可以在病历展示界面中查看需要进行评价的电子病历。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.
在本实施例中,在预设的病历展示界面中展示在步骤S104中获取到的至少一个属性项,需要说明的是,在展示目标病历的所有的属性项时,展示的信息包括有与该属性项对应的属性项标签(例如,图2中编号L3所示),以及与该属性项对应的属性值。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.
进一步的,为了相关的病历检查人员或者病历评价人员在进行病历评价时的操作方便,在展示目标病历的每一个属性项时,还展示了与该属性项对应的属性值评价组件,例如,在展示的属性项的属性项标签旁、或者展示页面与该属性项的展示区域对应的预设的属性值评价组件展示区域,展示了用户可以进行输入的属性值评价组件。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.
需要说明的是,在本实施例中,属性值评价组件中包含了可以被选择的评价标签,并且,可以选择的评价标签可以不止一个。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.
在如图3所示的应用场景中,编号L4所示的即为属性值评价组件,用户可以通过该属性值评价组件输入该属性项对应的属性值对应的评价。在一个具体的实施例中,如图3所示,属性值评价组件为包含了多个评价标签的下拉选
择框,用户可以通过该下拉选择框选择需要输入的评价标签。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.
步骤S108:确定用户通过所述展示的属性值评价组件选择的评价标签作为与该属性项对应的目标评价标签,所述目标评价标签的数量至少为一。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.
如前所述,用户可以通过展示的属性值评价组件,选择对于当前的属性项对应的属性值评价所对应的预设的评价标签,例如,对于“过敏史”项,评价标签可以为“药物过敏未填写”、或者“过敏史填写不规范”等。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".
需要说明的是,在本实施例中,针对某一个属性项,可以输入的评价标签不止一个,具体可以根据系统设置来进行确定,也就是说,可以预先在系统中设置可以输入的评价标签的数量至多一个,也可以设置可以输入的评价标签的数量可以超过一个。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.
因为不同的属性项可能存在的填写问题也会不一样,例如,“过敏史”项与“病人主诉病史”项所可能存在的问题不同,因此,如果针对所有的属性项均采用相同的评价标签,则会存在评价标签的精准度不高的问题。因此,对于不同的属性项设置不同的评价标签,从而提高电子病历评价的准确度。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.
具体的,对于需要展示的属性项,确定与该属性项对应的标签列表,所述标签列表包括预设的至少一个评价标签。也就是说,在预设的属性项与评价标签的对应关系中,确定与当前的属性项对应的评价标签或者评价标签列表。并且,对于一个属性项而言,其对应的预先设置的评价标签的数量可以不止一个。然后,根究确定的评价标签列表或者评价标签生成与对应的属性项对应的属性值评价组件,该生成的属性值评价组件与该属性项是对应的,并且,包含了上述确定的多个评价标签或者包含了上述确定的评价标签列表中包含的所有的评价标签。然后,在展示目标病历以及目标病历的至少一个属性项时,展示的属性值评价组件即为上述生成的属性值评价组件。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.
例如,在图3所示的应用场景中,用户可以通过点击编号L5所示的下拉选择框来展示所有的可以选择的评价标签,然后从展示的评价标签中选择需要输入的评价标签,作为当前属性项对应的目标评价标签。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.
需要说明的是,在本实施例中,对于某一个属性项而言,其对应的目标评价标签可以为空。也就是说,用户可以在没有对部分属性项选择与之对应的目标评价标签的情况下,提交对当前的目标病历的评价。
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.
步骤S110:根据预设的评价标签与评价分值之间的对应关系以及确定的目标评价标签,确定与该属性项对应的属性项评价分值。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.
对于不同的评价标签,其所对应的病历填写情况和水平也不一样,例如,“病人主诉病史”项中,评价标签“无主诉病史”和“主诉描述不清楚”所对应的问题不同,在给电子病历的填写进行评价或者评分的过程中,其对电子评价的最终评价结果的贡献也会不一样。因此,不同的评价标签对应的评价分值也不相同。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.
在本实施例中,预先设置了各个评价标签与评价分值之间的对应关系,例如,“药物过敏未填写”对应的评价分值为“-2分”,“无入院记录”对应的评价分值为“-25分”。在目标评价标签确定的情况下,根据上述预设的评价标签与评价分值之间对应关系可以确定与每一个目标评价标签对应的评价分值。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.
然后根据属性项所对应的所有的目标评价标签以及与每一个目标评价标签对应的评价分值,确定与该属性项对应的属性项评价分值。例如,对指定的属性项,将该属性项对应的所有的目标评价标签对应的评价分值的和,即为该属性项的属性项评价分值。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.
步骤S112:根据预设的病历评价算法以及与至少一个属性项对应的属性项评价分值,计算与所述目标病历对应的总评价分值。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.
在本实施例中,预先设置了电子病历的总评价分值的计算方法,例如,通过计算每一个属性项的属性项评价分值的和作为对应的电子病历的总评价分值,或者,通过预设的总评价分值计算公式,以每一个属性项的属性项评价分值作为自变量,计算对应的电子病历的总评价分值。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.
在本实施例中,在目标病历确定的情况下,根据目标病历的每一个属性项的属性值和对应的属性项评价分值,以及预设的病历评价算法,即可计算与当前的目标病历对应的总评价分值。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.
例如,在一个具体的实施例中,目标病历D-Target包含了N个属性项A1,A2,…,AN,其对应的属性值为a1,a2,…,aN,与属性项Ai对应的属性项评价分值为xi,计算与目标病历D-Target的总评价分值Starget可以通过如下公式(1)、(2)或(3)进行计算:
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):
其中,αiXX为与Ai对应的权重系数,K为一大于0且小于100的常数。Where α i XX is a weight coefficient corresponding to A i , and K is a constant greater than 0 and less than 100.
进一步的,上述根据预设的病历评价算法以及与至少一个属性项对应的属性项评价分值计算与所述目标病历对应的总评价分值具体为:获取预设的与每一个属性项对应的权重系数作为目标权重系数;根据所述与至少一个属性项对应的属性项评价分值以及所述目标权重系数,计算与所述目标病历对应的总评价分值。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.
也就是说每一个属性项对应的权重系数不一样,不同的属性项对于总评价分值的贡献是不一样的,例如,“病程记录”对应的权重系数大于“医嘱”对应的权重系数。在本实施例中,预先设置了每一个属性项对应的权重系数,在本步骤中,在计算目标病历的总评价分值时,是根据每一个属性项对应的权重系数以及该属性项对应的属性项评价分值来计算目标病历的总评价分值的。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.
需要说明的是,目标病历的总评价分值的计算方法不限于上述。It should be noted that the calculation method of the total evaluation score of the target medical record is not limited to the above.
步骤S114:在所述预设的病历展示界面上展示所述总评价分值。Step S114: Display the total evaluation score on the preset medical record display interface.
在本实施例中,在用户提交了对于目标病历的评价之后,即可根据用户的选择计算对应的总评价分值,并且,在当前的目标病历的展示界面上展示对应的总评价分值。进一步的,在相应的病历列表中,也可以展示与每一个进行评价过的电子病历的总评价分值。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.
进一步的,在本实施例中,在对每一个电子病历进行评价之后,不仅需要在相应的页面展示相应的电子病历的总评价分值,在总评价分值过低时,还需要进行提醒。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.
具体的,上述根据预设的病历评价算法以及与至少一个属性项对应的属性
项评价分值计算与所述目标病历对应的总评价分值之后还包括:判断所述总评价分值是否小于预设的分数阈值,在所述总评价分值小于所述预设的分数阈值的情况下,获取所述确定的目标评价标签;根据所述获取的目标评价标签对所述目标病历进行标记,并将所述目标病历标记为问题病历。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.
总评价分值过低说明该电子病历的填写情况存在较大的问题,应该进行修正或者提醒相应的科室进行惩处、或者在后期的病历填写中进行改正。因此,在本实施例中,在目标病历的总评价分值确定之后,还需要判断计算得到的总评价分值是否满足预设的分值条件,例如,是否大于或等于预设的分数阈值,并且,在目标病历的总评价分值小于预设的分数阈值的情况下,确定该目标病历为问题病历,并将目标病历标记为问题病历。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.
进一步的,为了方便用户对问题病历存在的问题进行查看,或者统计所有的问题病历所存在的相关缺陷,在本实施例中,除了将总评价分值不满足预设的分值条件的电子病历标记为问题病历之后,还将属性项评价分值对应的属性项的属性项标签也标记为问题病历的标签。进一步的,因为评价标签是对目标病历的某一个属性项所存在的问题进行评价的标签,也就是说,目标评价标签可以表明该目标病历存在的问题,因此,在本实施例中,还需要将对目标病历进行评价的过程中确定的所有的目标评价标签也加入到问题病历的标签中。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.
需要说明的是,在本实施例中,用户可以手动的对电子病历的每一个属性项是否存在某种缺陷进行检查和标签,但是,对于电子病历的评价不限于用户的手动标签,还可以包括计算机的自动评价。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.
例如,对于电子病历中的必须填写的属性项(必填项),如果相关医护人员在填写的过程中没有填写,即必填项的属性值为空白的情况下,电子病历关系系统或电子病历的评价系统自动的对必填项的属性值是否为空进行检测,并根据预设的必填项评价分值的评价规则,给出对应的属性项评价分值。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.
在另一个具体的实施例中,不仅可以自动的对属性值是否为空进行检测,还可以检测属性项的属性值是否满足预设的条件,例如,“出生年月”是否在指定的范围之内,再例如,“用药须知”是否包含了规定的规范内容,再例如,“手术记录”的填写时间是否在手术时间完成之后的2个小时之内等。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.
具体的,在一个实施例中,在获取所述目标病历的至少一个属性项的步骤之后,
还包括:遍历所述至少一个属性项,对于遍历到的属性项,获取预设的与该属性项对应的属性值填写规则,根据获取到的属性值填写规则以及与该属性项对应的属性值,计算与该属性项对应的属性项评价分值;根据预设的病历评价算法以及与至少一个属性项对应的属性项评价分值计算与所述目标病历对应的总评价分值。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.
也就是说,对于每一个属性项,确定与该属性项对应的属性值填写规则,并根据该属性值填写规则对该属性项的属性值进行评价,并计算对应的属性项评价分值,该分值可以用于最终的总评价分值的计算。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.
此外,为解决传统技术中的在用户与其他用户通过即时通讯应用或者社交网络平台进行聊天的过程中在存在风险时对用户进行提醒的有效率不足的技术问题,在一个实施例中,如图4所示,还提出了一种电子病历的评价装置,包括: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:
病历确定模块102,用于获取选择的电子病历作为目标病历,获取所述目标病历的至少一个属性项,所述每一个属性项包括与该属性项对应的的属性值;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;
病历展示模块104,用于在预设的病历展示界面上展示所述获取到的至少一个属性项以及与该属性项对应的属性值评价组件,所述属性值评价组件包括至少一个评价标签;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;
属性项评价分值确定模块106,用于确定用户通过所述展示的属性值评价组件选择的评价标签作为与该属性项对应的目标评价标签,所述目标评价标签的数量至少为一;根据预设的评价标签与评价分值之间的对应关系以及确定的目标评价标签,确定与该属性项对应的属性项评价分值;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;
总评价分值计算模块108,用于根据预设的病历评价算法以及与至少一个属性项对应的属性项评价分值,计算与所述目标病历对应的总评价分值,并在所述预设的病历展示界面上展示所述总评价分值。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.
可选的,在一个实施例中,属性项评价分值确定模块106还用于遍历所述至少一个属性项,对于遍历到的属性项,获取预设的与该属性项对应的属性值填写规则,根据获取到的属性值填写规则以及与该属性项对应的属性值,计算与该属性项对应的属性项评价分值;调用所述总评价分值计算模块108。
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.
可选的,在一个实施例中,如图4所示,上述装置还包括属性值评价组件生成模块110,用于对于每一个属性项,确定与该属性项对应的标签列表,所述标签列表包括预设的至少一个评价标签;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;
所述病历展示模块104还用于根据所述确定的标签列表生成与该属性项对应的属性值评价组件,所述属性值评价组件包含所述预设的至少一个评价标签;在所述预设的病历展示界面上展示所述属性项以及对应的属性值评价组件。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.
可选的,在一个实施例中,总评价分值计算模块108还用于获取预设的与每一个属性项对应的权重系数作为目标权重系数;根据所述与至少一个属性项对应的属性项评价分值以及所述目标权重系数,计算与所述目标病历对应的总评价分值。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.
可选的,在一个实施例中,如图4所示,上述装置还包括问题病历标记模块112,用于判断所述总评价分值是否小于预设的分数阈值,在所述总评价分值小于所述预设的分数阈值的情况下,获取所述确定的目标评价标签;根据所述获取的目标评价标签对所述目标病历进行标记,并将所述目标病历标记为问题病历。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.
实施本发明实施例,将具有如下有益效果:Implementation of the embodiments of the present invention will have the following beneficial effects:
采用了上述电子病历的评价方法和装置之后,对于运行中的电子病历,用户可以通过相应的病例展示界面,对展示的电子病历的每一个属性项对应的属性值的填写是否满足规则进行检查,并且,通过展示的与该属性项对应的属性值评价组件来选择对于该属性项的属性值对应的评价标签,其中每一个评价标签都存在一个预设的对应的评分,根据该评分即可确定每一个进行评价了的属性项对应的评分;最后,通过预设的电子病历评价算法、以及每一个属性项对应的评分,计算展示的电子病历的总评分并进行展示,即为总评价分值。也就是说,采用了本发明中的电子病历的评价方法和装置之后,可以通过对每一个属性项进行标签的方法来实现对电子病历的自动评价,提高电子病历评价的准确度和可信度。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. .
进一步的,只要是可以进行查看的电子病历均可以对其进行评价,这就使得在病人住院的每一个阶段,相应的质控人员等均可以对运行中的电子病历或
者已经归档的终末病例进行评价,提高了电子病历的评价方法的适用范围。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.
在上述实施例中,可以全部或部分的通过软件、硬件、固件或者其任意组合来实现。当使用软件程序实现时,可以全部或部分地以计算机程序产品的形式实现。所述计算机程序产品包括一个或多个计算机指令。在计算机上加载和执行所述计算机程序指令时,全部或部分地产生按照本发明实施例所述的流程或功能。所述计算机可以是通用计算机、专用计算机、计算机网络、或者其他可编程装置。所述计算机指令可以存储在计算机可读存储介质中,或者从一个计算机可读存储介质向另一个计算机可读存储介质传输,例如,所述计算机指令可以从一个网站站点、计算机、服务器或者数据中心通过有线(例如同轴电缆、光纤、数字用户线(DSL))或无线(例如红外、无线、微波等)方式向另一个网站站点、计算机、服务器或者数据中心进行传输。所述计算机可读存储介质可以是计算机能够存取的任何可用介质或者是包含一个或多个可用介质集成的服务器、数据中心等数据存储设备。所述可用介质可以是磁性介质,(例如,软盘、硬盘、磁带)、光介质(例如,DVD)、或半导体介质(例如固态硬盘Solid State Disk(SSD))等。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.
在一个实施例中,如图5所示,图5展示了一种运行上述电子病历的评价方法的基于冯诺依曼体系的计算机系统的终端。该计算机系统可以是智能手机、平板电脑、掌上电脑、笔记本电脑或个人电脑等终端设备。具体的,可包括通过系统总线连接的外部输入接口1001、处理器1002、存储器1003和输出接口1004。其中,外部输入接口1001可选的可至少包括网络接口10012。存储器1003可包括外存储器10032(例如硬盘、光盘或软盘等)和内存储器10034。输出接口1004可至少包括显示屏10042等设备。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.
在本实施例中,本方法的运行基于计算机程序,该计算机程序的程序文件存储于前述基于冯诺依曼体系的计算机系统的外存储器10032中,在运行时被加载到内存储器10034中,然后被编译为机器码之后传递至处理器1002中执行,从而使得基于冯诺依曼体系的计算机系统中形成逻辑上的各个模块。且在上述电子病历的评价方法执行过程中,输入的参数均通过外部输入接口1001
接收,并传递至存储器1003中缓存,然后输入到处理器1002中进行处理,处理的结果数据或缓存于存储器1003中进行后续地处理,或被传递至输出接口1004进行输出。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.
以上所揭露的仅为本发明较佳实施例而已,当然不能以此来限定本发明之权利范围,因此依本发明权利要求所作的等同变化,仍属本发明所涵盖的范围。
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 (10)
- 一种电子病历的评价方法,其特征在于,包括:An evaluation method for an electronic medical record, comprising:获取选择的电子病历作为目标病历,获取所述目标病历的至少一个属性项,所述每一个属性项包括与该属性项对应的的属性值;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;在预设的病历展示界面上展示所述获取到的至少一个属性项以及与该属性项对应的属性值评价组件,所述属性值评价组件包括至少一个评价标签;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;确定用户通过所述展示的属性值评价组件选择的评价标签作为与该属性项对应的目标评价标签,所述目标评价标签的数量至少为一;根据预设的评价标签与评价分值之间的对应关系以及确定的目标评价标签,确定与该属性项对应的属性项评价分值;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;根据预设的病历评价算法以及与至少一个属性项对应的属性项评价分值,计算与所述目标病历对应的总评价分值,并在所述预设的病历展示界面上展示所述总评价分值。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.
- 根据权利要求1所述的电子病历的评价方法,其特征在于,所述获取所述目标病历的至少一个属性项之后还包括: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:遍历所述至少一个属性项,对于遍历到的属性项,获取预设的与该属性项对应的属性值填写规则,根据获取到的属性值填写规则以及与该属性项对应的属性值,计算与该属性项对应的属性项评价分值;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;执行所述根据预设的病历评价算法以及与至少一个属性项对应的属性项评价分值计算与所述目标病历对应的总评价分值。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.
- 根据权利要求1所述的电子病历的评价方法,其特征在于,所述在预设的病历展示界面上展示所述获取到的至少一个属性项以及与该属性项对应的属性值评价组件之前还包括: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:对于每一个属性项,确定与该属性项对应的标签列表,所述标签列表包括预设的至少一个评价标签; Determining, for each attribute item, a tag list corresponding to the attribute item, the tag list including a preset at least one evaluation tag;所述在预设的病历展示界面上展示所述获取到的至少一个属性项以及对应的属性值评价组件还包括:The displaying the at least one attribute item and the corresponding attribute value evaluation component on the preset medical record display interface further includes:根据所述确定的标签列表生成与该属性项对应的属性值评价组件,所述属性值评价组件包含所述预设的至少一个评价标签;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;在所述预设的病历展示界面上展示所述属性项以及对应的属性值评价组件。The attribute item and the corresponding attribute value evaluation component are displayed on the preset medical record display interface.
- 根据权利要求1所述的电子病历的评价方法,其特征在于,所述根据预设的病历评价算法以及与至少一个属性项对应的属性项评价分值计算与所述目标病历对应的总评价分值还包括: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:获取预设的与每一个属性项对应的权重系数作为目标权重系数;Obtaining a preset weight coefficient corresponding to each attribute item as a target weight coefficient;根据所述与至少一个属性项对应的属性项评价分值以及所述目标权重系数,计算与所述目标病历对应的总评价分值。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.
- 根据权利要求1所述的电子病历的评价方法,其特征在于,所述根据预设的病历评价算法以及与至少一个属性项对应的属性项评价分值计算与所述目标病历对应的总评价分值之后还包括: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:判断所述总评价分值是否小于预设的分数阈值,在所述总评价分值小于所述预设的分数阈值的情况下,获取所述确定的目标评价标签;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;根据所述获取的目标评价标签对所述目标病历进行标记,并将所述目标病历标记为问题病历。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.
- 一种电子病历的评价装置,其特征在于,包括:An evaluation device for an electronic medical record, comprising:病历确定模块,用于获取选择的电子病历作为目标病历,获取所述目标病历的至少一个属性项,所述每一个属性项包括与该属性项对应的的属性值;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;病历展示模块,用于在预设的病历展示界面上展示所述获取到的至少一个属性项以及与该属性项对应的属性值评价组件,所述属性值评价组件包括至少一个评价标签;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;属性项评价分值确定模块,用于确定用户通过所述展示的属性值评价组件 选择的评价标签作为与该属性项对应的目标评价标签,所述目标评价标签的数量至少为一;根据预设的评价标签与评价分值之间的对应关系以及确定的目标评价标签,确定与该属性项对应的属性项评价分值;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;总评价分值计算模块,用于根据预设的病历评价算法以及与至少一个属性项对应的属性项评价分值,计算与所述目标病历对应的总评价分值,并在所述预设的病历展示界面上展示所述总评价分值。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.
- 根据权利要求6所述的电子病历的评价装置,其特征在于,所述属性项评价分值确定模块还用于遍历所述至少一个属性项,对于遍历到的属性项,获取预设的与该属性项对应的属性值填写规则,根据获取到的属性值填写规则以及与该属性项对应的属性值,计算与该属性项对应的属性项评价分值;调用所述总评价分值计算模块。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.
- 根据权利要求6所述的电子病历的评价装置,其特征在于,所述装置还包括属性值评价组件生成模块,用于对于每一个属性项,确定与该属性项对应的标签列表,所述标签列表包括预设的至少一个评价标签;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;所述病历展示模块还用于根据所述确定的标签列表生成与该属性项对应的属性值评价组件,所述属性值评价组件包含所述预设的至少一个评价标签;在所述预设的病历展示界面上展示所述属性项以及对应的属性值评价组件。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.
- 根据权利要求6所述的电子病历的评价装置,其特征在于,所述总评价分值计算模块还用于获取预设的与每一个属性项对应的权重系数作为目标权重系数;根据所述与至少一个属性项对应的属性项评价分值以及所述目标权重系数,计算与所述目标病历对应的总评价分值。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.
- 根据权利要求6所述的电子病历的评价装置,其特征在于,所述装置还包括问题病历标记模块,用于判断所述总评价分值是否小于预设的分数阈值,在所述总评价分值小于所述预设的分数阈值的情况下,获取所述确定的目标评价标签;根据所述获取的目标评价标签对所述目标病历进行标记,并将所述目 标病历标记为问题病历。 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.
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