The invention discloses a
system for generating a structured
electronic medical record. The
system is characterized by comprising symptom and sign dictionaries, a field conjunction management module, a
medical record modification module and a
medical record writ generating module. The multiple symptom and sign dictionaries are provided for selection by a doctor, different symptom and sign dictionaries are configured for different departments, each symptom and sign dictionary exists in a field mode, and the content of each field is a symptom and sign dictionary module in a structured point-and-click mode; according to the field conjunction management module, multiple conjunctions and
punctuation marks are provided, the conjunctions and / or the
punctuation marks are added in front and / or behind the fields in the selected symptom and sign dictionaries to form a field conjunction management module of a fluent
medical record language; the medical
record modification module is used for providing an interface for modifying the medical
record by the doctor; the medical
record document generating module is used for generating and displaying a final medical record document. The
system has the advantages that a lot of time is saved for medical workers, and better services are provided for a hospital and patients; the proof capacity for a medical dispute is improved; the normalization of the medical record is improved; first-hand and valuable documents are provided for scientific research, teaching and statistic analysis.