Electronic medical record information correction method and system
An information correction, electronic medical record technology, applied in the field of information processing, can solve the problems of improving the quality of medical records and diagnosis and treatment process, unable to help doctors, and improving the efficiency of writing medical records, so as to avoid medical accidents, improve efficiency, and improve quality.
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Embodiment 1
[0048] This embodiment discloses a method for correcting electronic medical record information, which obtains the required data from the hospital's HIS, LIS, PACS, and EMR systems (the four systems correspond to doctor's order, inspection, inspection, and medical record information respectively), and on server A After processing, the result is sent to the client where the doctor writes the medical record.
[0049] The medical record includes the following three parts: admission record, course record, and discharge record. The course record is divided into three types, namely, the first course record, the course record of the first ward round, and the follow-up course record.
[0050] See attached figure 1 As shown, step (1): establish a medical knowledge map, the knowledge map includes symptoms->diagnosis, signs->diagnosis, test results->diagnosis, test results->diagnosis, diagnosis->medicine, diagnosis->medical operations (including inspection, testing, surgery, etc.), the k...
Embodiment 2
[0111] An electronic medical record information correction system, including a server, the server is configured to:
[0112] Establish a medical knowledge graph;
[0113] Receive the admission record information of newly admitted patients, and receive the admission record information of this patient based on the admission record and discharge record information of the patient's previous admission for patients who are re-admitted due to the same disease, and assist in writing the patient's admission record;
[0114] Receive the first course record information based on the patient's admission record, latest inspection results, and doctor's order information, and assist in completing the first course record;
[0115] Receive the first ward round medical course record information based on the first medical course record, the latest inspection results, and doctor's order information, and assist in completing the first ward round medical course record;
[0116] Receive the follow-u...
Embodiment 3
[0122] A computer device, comprising a memory, a processor, and a computer program stored on the memory and operable on the processor, wherein the processor implements the following steps when executing the program:
[0123] Establish a medical knowledge graph;
[0124] Receive the admission record information of newly admitted patients, and receive the admission record information of this patient based on the admission record and discharge record information of the patient's previous admission for patients who are re-admitted due to the same disease, and assist in writing the patient's admission record;
[0125] Receive the first course record information based on the patient's admission record, latest inspection results, and doctor's order information, and assist in completing the first course record;
[0126] Receive the first ward round medical course record information based on the first medical course record, the latest inspection results, and doctor's order information,...
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