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Quality control method and apparatus for electronic medical record

A quality control method and technology of electronic medical records, applied in the field of medical system informatization, can solve the problems of low efficiency of quality and air flow, manual review, inability to timely reflect the quality of medical records, etc., and achieve the effect of improving efficiency and simplifying the processing process.

Inactive Publication Date: 2016-07-27
宁波金唐软件有限公司
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  • Abstract
  • Description
  • Claims
  • Application Information

AI Technical Summary

Problems solved by technology

[0004] The embodiment of the present invention provides a quality control method and device for electronic medical records, aiming to solve the technical problems that the quality control process of electronic medical records requires manual review, the efficiency of the quality-empty process is low, and the quality of medical records cannot be reflected in a timely manner.

Method used

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  • Quality control method and apparatus for electronic medical record
  • Quality control method and apparatus for electronic medical record

Examples

Experimental program
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Effect test

Embodiment 1

[0036] figure 2 The flow chart of a quality control method for electronic medical records provided by an embodiment of the present invention is shown, and the details are as follows:

[0037] In step S201, electronic medical record data is acquired.

[0038] Wherein, the electronic medical record data is structured electronic medical record data. The electronic medical record data is a collection of patient information in a structured electronic medical record with a four-layer storage structure. The four-layer storage structure includes metadata, data groups, document segments and medical record files. The specific actual application conditions are as follows :

[0039] 1) Metadata: including symptom metadata, anatomical part metadata, time metadata, quantity metadata, logical judgment metadata, etc. For example, "diarrhea" belongs to symptom metadata.

[0040] 2) Data group: composed of several metadata, for example, a paragraph describing the symptom of "diarrhea" belon...

Embodiment 2

[0056] In the embodiment of the present invention, the quality control condition is whether the diagnostic data conforms to the symptom description.

[0057] image 3 It shows the process of judging whether the electronic medical record data meets the quality control conditions provided by the embodiment of the present invention, and the details are as follows:

[0058] In step S301, the diagnostic data and symptom description in the electronic medical record data are acquired.

[0059] In step S302, the symptom descriptions are analyzed to obtain key words about the disease in several symptom descriptions.

[0060] For example, the symptom description mainly describes the irregular menstruation of a female patient. At this time, the key words about the disease should include words such as "menstruation", "abdominal pain", and "duration".

[0061] Since the structured storage of electronic medical records is very common, the embodiment of the present invention aims at the el...

Embodiment 3

[0066] In the embodiment of the present invention, the number of the quality control conditions is two or more.

[0067] It should be applicable to the situation where multiple quality control conditions are used in the electronic medical record scoring process at the same time.

[0068] Figure 4 It shows the process of obtaining the quality score of the electronic medical record according to the judgment result and the quality control rule corresponding to the quality control condition provided by the embodiment of the present invention. The quantity of the quality control conditions is two or more. The details are as follows:

[0069] In step S401, according to the judgment result, the grade score corresponding to the quality control condition is obtained.

[0070] For example, when the quality control condition is "whether the admission record is completed within 24 hours", if the judgment result is "Yes", the grade score is "10 points", which means adding 10 points; if...

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Abstract

The invention is suitable for the technical field of medical system informationization and provides a quality control method for an electronic medical record. The method comprises the steps of obtaining electronic medical record data, wherein the electronic medical record data is structured electronic medical record data; judging whether the electronic medical record data meets a quality control condition or not; according to a judgment result and a quality control rule corresponding to the quality control condition, obtaining a quality score of the electronic medical record; and storing the quality score of the electronic medical record. According to an embodiment of the invention, the step of scoring the structured electronic medical record data is added, so that a doctor can visually know a true condition of the medical record through the quality score, the quality control doctor can finish the quality control of the medical record through the configured quality control condition, and a handling process of the quality control doctor is greatly simplified; and meanwhile, in the whole quality control process, the doctor can configure the required quality control condition, so that the quality score can more truly reflect the quality condition of the electronic medical record.

Description

technical field [0001] The invention belongs to the technical field of medical system informatization, and in particular relates to a quality control method and device for electronic medical records. Background technique [0002] Medical records refer to the sum of text, charts, images, slices and other materials formed by medical personnel in the course of medical activities. They are materials with legal significance and powerful proof materials for inversion of evidence. Today, with the increasing development of information technology, electronic medical record systems have gradually become popular in hospitals at all levels. Compared with the traditional paper medical records in the past, electronic medical records have the characteristics of convenient writing, convenient interaction, and flexible access. Its appearance is convenient for medical staff. Writing and querying have improved work efficiency, but some medical record quality problems have also emerged, and hav...

Claims

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Application Information

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IPC IPC(8): G06F19/00G06Q50/24G16H10/60
CPCG06Q50/24G16H10/60
Inventor 邬金国
Owner 宁波金唐软件有限公司
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