Medical record writing quality control method and system
A quality control method and medical record technology, applied in the field of medical record management, can solve the problems of medical record quality control lag, poor quality, and failure to remind in time, and achieve the effect of good real-time performance and high writing quality
- Summary
- Abstract
- Description
- Claims
- Application Information
AI Technical Summary
Problems solved by technology
Method used
Image
Examples
Embodiment 1
[0043] See figure 1 as well as figure 2 This embodiment provides a quality control method for medical record writing. The quality control method is used for quality control of medical records written by doctors. It mainly includes two closed-loop quality control processes, one of which is automated closed-loop quality control for doctors based on NLP technology, and the other One is based on NLP technology to automate QC closed-loop quality control. The quality control method of this embodiment can be implanted in the electronic medical record system in the form of a quality control AI assistant, and combined with the standard data set of the medical record, data elements, range dictionary, quality control rule library and other knowledge base data, it can provide the basic health service center, Quality control and management of medical records generated in hospitals and other medical places. Among them, the quality control method includes the following steps.
[0044] When t...
Embodiment 2
[0063] This embodiment provides a method for quality control of medical record writing, which defines the content of the time limit rule on the basis of Embodiment 1. Among them, the time limit rule one includes that the medical record needs to complete the first course of the disease within a preset time of admission (for example: the first course of illness is completed within 8 hours of admission), and the writing time of the medical record must be less than a preset time of 2. The first time limit rule can ensure the efficiency of writing medical records. Both the preset time one and the preset time two can be determined according to different departments, different doctors and different diseases. The second time limit rule includes that the first processing time of the medical record needs to be less than a preset time 3, the medical record modification time needs to be less than a preset time 4, and the medical record completion time needs to be less than a preset time 5. ...
Embodiment 3
[0065] This embodiment provides a method for quality control of medical record writing, which limits data integrity on the basis of Embodiment 1. Among them, the data integrity rule 1 or the data integrity rule 2 includes whether the diagnosis data in the medical record must be missing, the examination data in the medical record must be missing, and the examination items in the medical record must meet the check items related to the patient's condition description , The medical record should indicate the number and amount of use of the drugs prescribed by the doctor each day, and the medical record should indicate the patient’s review time and review information. In this embodiment, the first data integrity rule or the second data integrity rule are the same. Checking the integrity of these data can improve the writing quality of medical records, so that patients can view the information they need in time based on the medical records, thereby improving the quality of medical se...
PUM
Abstract
Description
Claims
Application Information
- R&D Engineer
- R&D Manager
- IP Professional
- Industry Leading Data Capabilities
- Powerful AI technology
- Patent DNA Extraction
Browse by: Latest US Patents, China's latest patents, Technical Efficacy Thesaurus, Application Domain, Technology Topic, Popular Technical Reports.
© 2024 PatSnap. All rights reserved.Legal|Privacy policy|Modern Slavery Act Transparency Statement|Sitemap|About US| Contact US: help@patsnap.com