Medical record home page diagnosis information quality control method and system based on informatization processing

Abstract

The invention provides a medical record home page diagnosis information quality control method and system based on informatization processing, and the method comprises the steps: receiving all fields on an input medical record, and packaging the fields to form a regular line character string; forming a medical record home page content object based on the field; initializing rules written in the database to form a rule cache; reflecting into an expected object according to an initialization program flow; the filled content is sent to a quality control interface, so that the program in all the reflected rule content is subjected to quality control; each rule in the database contains a corresponding template, and home page transmission data is combined with the corresponding template; and auditing the home page content, modifying the home page content of the medical record through an error prompt, and continuing the medical record process until the medical record content meets the requirement. According to the method, logic quality control and reminding are carried out on the codes by utilizing an informatization tool, and the accuracy of main diagnosis codes is improved.

Description

technical field [0001] The invention belongs to the technical field of information processing, and in particular relates to a method and system for quality control of diagnosis information on the front page of a medical record based on information processing. Background technique [0002] The statements in this section merely provide background information related to the present invention and do not necessarily constitute prior art. [0003] The homepage information of inpatient medical records is an important part of medical record management, which reflects the medical quality and management level of doctors, and is very important for the statistics of disease diagnosis and treatment, payment of diseases, and disease spectrum. As the reform and exploration of the payment method of disease diagnosis-related groups (DRGs) continue to deepen, the accuracy of ICD coding for diagnosis and surgical operations as an important source of information is particularly important, which...

AI Technical Summary

Problems solved by technology

[0009] 1. Most of them are for the formal quality control of required items, value ranges, etc. for filling in the content of the home page, and there are relatively few connotative quality controls based on the principles of coding and diagnostic selection

[0010] 2. Although some products involve internal quality control content, they are also sporadic quality control, which is not comprehensive. It only provides mechanized prompts for the main diagnosis and the prompts are inaccurate, which cannot be combined with the actual clinical situation.

[0011] 3. The commonly used quality control process is: after the medical records are returned to the medical record room, the coders or quality control personnel will conduct quality control on the content filled in by the doctor, and the doctor will be required to modify the non-standard diagnostic information. This process usually takes several days, and the clinical The work of doctors is heavy, some doctors do not modify directly

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