Method and device for generating electronic medical record, computer device and storage medium

Abstract

The invention relates to a method and device for generating an electronic medical record, a computer device and a storage medium. The method comprises the following steps of: receiving an electronic medical record generation instruction, wherein the electronic medical record generation instruction carries a user identifier; acquiring first medical record information and diagnosis information corresponding to the user identifier from a hospital server; judging whether abnormal results exist in the first medical record information according to a knowledge map; when an abnormal result exists, carrying out first marking on the first medical record information of the abnormal result; acquiring a correlation degree corresponding to the first medical record information of the normal result, wherein the correlation degree is the correlation degree of the first medical record information of the normal result and the diagnosis information; when the correlation degree is larger than a first threshold value, carrying out first marking processing on the first medical record information with the correlation degree larger than the first threshold value; and generating an electronic medical recordaccording to the first medical record information corresponding to the first mark processing. By adopting the method, the electronic medical record content can be optimized.

Description

technical field [0001] The present application relates to the field of computer technology, in particular to a method, device, computer equipment and storage medium for generating electronic medical records. Background technique [0002] The automatic generation of electronic medical records can reduce the workload of doctors in clinical practice, allowing them to spend more energy on patient diagnosis and treatment. [0003] The traditional electronic medical record generation system is mainly generated in the form of template filling. The template needs to be preset in advance, and different diseases require different templates, and the rule-based information collection methods such as templates make electronic medical records homogeneous, which is a reference for doctors. Weakened value. On the other hand, small templates cover less information, while broad templates contain a lot of invalid information, wasting hospital information resources, and are not conducive to do...

AI Technical Summary

Problems solved by technology

[0003] The traditional electronic medical record generation system is mainly generated in the form of template filling. The template needs to be preset in advance, and different diseases require different templates, and the rule-based information collection methods such as templates make electronic medical records homogeneous, which is a reference for doctors. Weakened value

On the other hand, small templates cover a small amount of information, while broad templates contain a lot of invalid information, wasting hospital information resources, and are not conducive to doctors' reading, decision-making, and later analysis and application of disease data.

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