CN103578066A - Patient-oriented clinical information organization system and method - Google Patents

Patient-oriented clinical information organization system and method Download PDF

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Publication number
CN103578066A
CN103578066A CN201310603582.8A CN201310603582A CN103578066A CN 103578066 A CN103578066 A CN 103578066A CN 201310603582 A CN201310603582 A CN 201310603582A CN 103578066 A CN103578066 A CN 103578066A
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China
Prior art keywords
information
patient
clinical
diagnosis
doctor
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CN201310603582.8A
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Chinese (zh)
Inventor
文黎明
龚健
郭云嵩
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Medical Information Technology Co Ltd Of Beijing University
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Founder International Co Ltd
Founder International Beijing Co Ltd
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Priority to CN201310603582.8A priority Critical patent/CN103578066A/en
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Abstract

The invention provides a patient-oriented clinical information organization system. The system comprises a structure building unit and a data management unit, wherein the structure building unit is used for building a clinical data structure including patient information, treatment information, doctors' advice information, execution records, medical records and execution process records; and the data management unit is used for associating diagnosis and treatment data with corresponding positions in the clinical data structure according to the corresponding type of the diagnosis and treatment data of each patient, so that storage and management of the diagnosis and treatment data of all patients are realized. The invention further provides a corresponding patient-oriented clinical information organization method. With the adoption of the technical scheme, all clinical data are patient-oriented, so that the management of the diagnosis and treatment data of the patients can be realized.

Description

Clinical information organization system centered by patient and clinical information method for organizing
Technical field
The present invention relates to medical information technical field, in particular to a kind of clinical information organization system and a kind of clinical information method for organizing centered by patient centered by patient.
Background technology
Existing clinical system is nearly all the demand based on progressively, scattered grows up, this organizational form that causes clinical data is also gradual expanding, develop into current situation, discovery is on existing data framework, want to realize the integrated of clinical function and the various functions such as support to integrated platform, need to readjust existing in disorder structure and could realize.
Summary of the invention
The present invention is just based on the problems referred to above, proposed a kind of new clinical information organizational technology centered by patient, can so that all clinical datas all centered by patient, thereby be convenient to realize the management to patient's diagnosis and treatment data.
In view of this, the present invention proposes a kind of clinical information organization system centered by patient, comprise: structure is set up unit, for setting up the clinical data structure that comprises patient information, diagnosis information, doctor's advice information, executive logging and medical history record, implementation record; Data Management Unit, for according to the type of diagnosis and treatment data corresponding to each patient, by described diagnosis and treatment data correlation to the relevant position in described clinical data structure, to realize the store and management to all patients' diagnosis and treatment data.
In this technical scheme, by setting up above-mentioned clinical data structure, make for a large amount of diagnosis and treatment data, can centered by patient information, build new data store organisation, contribute to the effective management to diagnosis and treatment data.
In technique scheme, preferably, described structure set up unit also for: in described clinical data structure, take described patient information as basis, set up other all information in described clinical data structure.
In this technical scheme, by take patient information as basis, set up other information, diagnosis information described above, doctor's advice information, executive logging and medical history record, implementation record etc., thereby make the framework of diagnosis and treatment data more clear, and centered by patient, be convenient to extended data structure and function, be also convenient to realize the integrated of clinical function and the support to integrated platform.
In technique scheme, preferably, described clinical data structure comprises a plurality of levels arranged side by side, and each level includes described patient information, described diagnosis information, described doctor's advice information, described executive logging and medical history record, described implementation record; Wherein, arbitrary patient generates a corresponding level when each going to a doctor.
In this technical scheme, by set up the clinical data of corresponding level when each medical, be convenient to set up and take the data structure that time shaft is direction, be convenient to checking diagnosis and treatment data.
In technique scheme, preferably, the medical type that arbitrary patient carries out comprises: outpatient clinic, emergency treatment are gone to a doctor, health check-up is medical and it is medical to be in hospital.
In technique scheme, preferably, all activities of arbitrary patient drive by described doctor's advice information.
In this technical scheme, because all having doctor's advice information, all activities drive, make the execution for arbitrary activity, can both be by management and supervision easily.
The invention allows for a kind of clinical information method for organizing centered by patient, comprising: set up the clinical data structure that comprises patient information, diagnosis information, doctor's advice information, executive logging and medical history record, implementation record; According to the type of diagnosis and treatment data corresponding to each patient, by described diagnosis and treatment data correlation to the relevant position in described clinical data structure, to realize the store and management to all patients' diagnosis and treatment data.
In this technical scheme, by setting up above-mentioned clinical data structure, make for a large amount of diagnosis and treatment data, can centered by patient information, build new data store organisation, contribute to the effective management to diagnosis and treatment data.
In technique scheme, preferably, also comprise: in described clinical data structure, take described patient information as basis, set up other all information in described clinical data structure.
In this technical scheme, by take patient information as basis, set up other information, diagnosis information described above, doctor's advice information, executive logging and medical history record, implementation record etc., thereby make the framework of diagnosis and treatment data more clear, and centered by patient, be convenient to extended data structure and function, be also convenient to realize the integrated of clinical function and the support to integrated platform.
In technique scheme, preferably, also comprise: described clinical data structure comprises a plurality of levels arranged side by side, each level includes described patient information, described diagnosis information, described doctor's advice information, described executive logging and medical history record, described implementation record; Wherein, arbitrary patient generates a corresponding level when each going to a doctor.
In this technical scheme, by set up the clinical data of corresponding level when each medical, be convenient to set up and take the data structure that time shaft is direction, be convenient to checking diagnosis and treatment data.
In technique scheme, preferably, the medical type that arbitrary patient carries out comprises: outpatient clinic, emergency treatment are gone to a doctor, health check-up is medical and it is medical to be in hospital.
In technique scheme, preferably, all activities of arbitrary patient drive by described doctor's advice information.
In this technical scheme, because all having doctor's advice information, all activities drive, make the execution for arbitrary activity, can both be by management and supervision easily.
By above technical scheme, can so that all clinical datas all centered by patient, thereby be convenient to realize the management to patient's diagnosis and treatment data.
Accompanying drawing explanation
Fig. 1 shows the schematic block diagram of the clinical information organization system centered by patient according to an embodiment of the invention;
Fig. 2 shows the schematic flow diagram of the clinical information method for organizing centered by patient according to an embodiment of the invention;
Fig. 3 shows the schematic diagram of clinical data structure according to an embodiment of the invention.
Embodiment
In order more clearly to understand above-mentioned purpose of the present invention, feature and advantage, below in conjunction with the drawings and specific embodiments, the present invention is further described in detail.It should be noted that, in the situation that not conflicting, the application's embodiment and the feature in embodiment can combine mutually.
Set forth in the following description a lot of details so that fully understand the present invention, still, the present invention can also adopt other to be different from other modes described here and implement, and therefore, the present invention is not limited to the restriction of following public specific embodiment.
Fig. 1 shows the schematic block diagram of the clinical information organization system centered by patient according to an embodiment of the invention.
As shown in Figure 1, clinical information organization system 100 centered by patient according to an embodiment of the invention, comprise: structure is set up unit 102, for setting up the clinical data structure that comprises patient information, diagnosis information, doctor's advice information, executive logging and medical history record, implementation record; Data Management Unit 104, for according to the type of diagnosis and treatment data corresponding to each patient, by described diagnosis and treatment data correlation to the relevant position in described clinical data structure, to realize the store and management to all patients' diagnosis and treatment data.
In this technical scheme, by setting up above-mentioned clinical data structure, make for a large amount of diagnosis and treatment data, can centered by patient information, build new data store organisation, contribute to the effective management to diagnosis and treatment data.
In technique scheme, preferably, described structure set up unit 102 also for: in described clinical data structure, take described patient information as basis, set up other all information in described clinical data structure.
In this technical scheme, by take patient information as basis, set up other information, diagnosis information described above, doctor's advice information, executive logging and medical history record, implementation record etc., thereby make the framework of diagnosis and treatment data more clear, and centered by patient, be convenient to extended data structure and function, be also convenient to realize the integrated of clinical function and the support to integrated platform.
In technique scheme, preferably, described clinical data structure comprises a plurality of levels arranged side by side, and each level includes described patient information, described diagnosis information, described doctor's advice information, described executive logging and medical history record, described implementation record; Wherein, arbitrary patient generates a corresponding level when each going to a doctor.
In this technical scheme, by set up the clinical data of corresponding level when each medical, be convenient to set up and take the data structure that time shaft is direction, be convenient to checking diagnosis and treatment data.
In technique scheme, preferably, the medical type that arbitrary patient carries out comprises: outpatient clinic, emergency treatment are gone to a doctor, health check-up is medical and it is medical to be in hospital.
In technique scheme, preferably, all activities of arbitrary patient drive by described doctor's advice information.
In this technical scheme, because all having doctor's advice information, all activities drive, make the execution for arbitrary activity, can both be by management and supervision easily.
Fig. 2 shows the schematic flow diagram of the clinical information method for organizing centered by patient according to an embodiment of the invention.
As shown in Figure 2, clinical information method for organizing centered by patient according to an embodiment of the invention, comprise: step 202, set up the clinical data structure that comprises patient information, diagnosis information, doctor's advice information, executive logging and medical history record, implementation record; Step 204, according to the type of diagnosis and treatment data corresponding to each patient, by described diagnosis and treatment data correlation to the relevant position in described clinical data structure, to realize the store and management to all patients' diagnosis and treatment data.
In this technical scheme, by setting up above-mentioned clinical data structure, make for a large amount of diagnosis and treatment data, can centered by patient information, build new data store organisation, contribute to the effective management to diagnosis and treatment data.
1, patient information (or patient's essential information)
Patient's essential information itself is clinical information not, but as the source of all clinical datas.He is the shared portion of all diagnosis information.
Mainly comprise following information:
1) patient's essential information
2) patient's address information
3) patient contact person
4) patient's medical insurance information
5) medical history
6) history of operation
7) allergies
8) immunity inoculation history
2, diagnosis information
Diagnosis information mainly comprises 4 classes: outpatient clinic, emergency treatment are gone to a doctor, health check-up is medical, it is medical to be in hospital.Mainly comprise following information:
1) diagnosis information
2) subscription information
3) information of registering
4) divide the information of examining
5) information of being admitted to hospital
6) information of transferring from one department to another
7) information of leaving hospital
8) preliminary examination information
3, doctor's advice information
Doctor's advice information is as the promoter of all curative activities, and it is all movable in institute almost to have included, and mainly comprises following information:
1) medication
2) Western medicine prescription
3) herbal medicine prescription
4) check doctor's advice
5) check doctor's advice
6) blood transfusion doctor's advice
7) operation doctor's advice
8) pathology doctor's advice
9) consultation of doctors doctor's advice
10) metacheirisis doctor's advice
11) meals doctor's advice
12) diagnosis and treatment activity
13) nursing activity
4, Executive records of doctor's order
Executive records of doctor's order essential record doctor's advice, at plan and the actual executing data of each execution point, mainly comprises:
1) Executive records of doctor's order
2) medical history record
3) NN
4) expense is detailed
5) Requisition for drugs
5, implementation record
Specifically refer to: all Status Change placement files that record all doctor's advices.
In technique scheme, preferably, also comprise: in described clinical data structure, take described patient information as basis, set up other all information in described clinical data structure.
In this technical scheme, by take patient information as basis, set up other information, diagnosis information described above, doctor's advice information, executive logging and medical history record, implementation record etc., thereby make the framework of diagnosis and treatment data more clear, and centered by patient, be convenient to extended data structure and function, be also convenient to realize the integrated of clinical function and the support to integrated platform.
Than as shown in Figure 3, be the clinical data structure based on a kind of concrete form of the present invention, wherein, centered by patient information, build its association to other information, contribute to the effective management to patient's diagnosis and treatment data.
Preferably, as shown in Figure 3, described clinical data structure comprises a plurality of levels arranged side by side, and each level includes described patient information, described diagnosis information, described doctor's advice information, described executive logging and medical history record, described implementation record; Wherein, arbitrary patient generates a corresponding level when each going to a doctor.
In this technical scheme, by set up the clinical data of corresponding level when each medical, be convenient to set up and take the data structure that time shaft is direction, be convenient to checking diagnosis and treatment data.
In technique scheme, preferably, the medical type that arbitrary patient carries out comprises: outpatient clinic, emergency treatment are gone to a doctor, health check-up is medical and it is medical to be in hospital.
In technique scheme, preferably, all activities of arbitrary patient drive by described doctor's advice information.
In this technical scheme, because all having doctor's advice information, all activities drive, make the execution for arbitrary activity, can both be by management and supervision easily.
More than be described with reference to the accompanying drawings technical scheme of the present invention, the present invention proposes a kind of clinical information organization system and a kind of clinical information method for organizing centered by patient centered by patient, can so that all clinical datas all centered by patient, thereby be convenient to realize the management to patient's diagnosis and treatment data.
The foregoing is only the preferred embodiments of the present invention, be not limited to the present invention, for a person skilled in the art, the present invention can have various modifications and variations.Within the spirit and principles in the present invention all, any modification of doing, be equal to replacement, improvement etc., within all should being included in protection scope of the present invention.

Claims (10)

1. the clinical information organization system centered by patient, is characterized in that, comprising:
Structure is set up unit, for setting up the clinical data structure that comprises patient information, diagnosis information, doctor's advice information, executive logging and medical history record, implementation record;
Data Management Unit, for according to the type of diagnosis and treatment data corresponding to each patient, by described diagnosis and treatment data correlation to the relevant position in described clinical data structure, to realize the store and management to all patients' diagnosis and treatment data.
2. the clinical information organization system centered by patient according to claim 1, is characterized in that, described structure set up unit also for:
In described clinical data structure, take described patient information as basis, set up other all information in described clinical data structure.
3. the clinical information organization system centered by patient according to claim 1, it is characterized in that, described clinical data structure comprises a plurality of levels arranged side by side, and each level includes described patient information, described diagnosis information, described doctor's advice information, described executive logging and medical history record, described implementation record;
Wherein, arbitrary patient generates a corresponding level when each going to a doctor.
4. the clinical information organization system centered by patient according to claim 3, is characterized in that, the medical type that arbitrary patient carries out comprises: outpatient clinic, emergency treatment are gone to a doctor, health check-up is medical and it is medical to be in hospital.
5. according to the clinical information organization system centered by patient described in any one in claim 1 to 4, it is characterized in that, all activities of arbitrary patient drive by described doctor's advice information.
6. the clinical information method for organizing centered by patient, is characterized in that, comprising:
Foundation comprises the clinical data structure of patient information, diagnosis information, doctor's advice information, executive logging and medical history record, implementation record;
According to the type of diagnosis and treatment data corresponding to each patient, by described diagnosis and treatment data correlation to the relevant position in described clinical data structure, to realize the store and management to all patients' diagnosis and treatment data.
7. the clinical information method for organizing centered by patient according to claim 6, is characterized in that, also comprises:
In described clinical data structure, take described patient information as basis, set up other all information in described clinical data structure.
8. the clinical information method for organizing centered by patient according to claim 6, is characterized in that, also comprises:
Described clinical data structure comprises a plurality of levels arranged side by side, and each level includes described patient information, described diagnosis information, described doctor's advice information, described executive logging and medical history record, described implementation record;
Wherein, arbitrary patient generates a corresponding level when each going to a doctor.
9. the clinical information method for organizing centered by patient according to claim 8, is characterized in that, the medical type that arbitrary patient carries out comprises: outpatient clinic, emergency treatment are gone to a doctor, health check-up is medical and it is medical to be in hospital.
10. according to the clinical information method for organizing centered by patient described in any one in claim 6 to 9, it is characterized in that, all activities of arbitrary patient drive by described doctor's advice information.
CN201310603582.8A 2013-11-25 2013-11-25 Patient-oriented clinical information organization system and method Pending CN103578066A (en)

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Cited By (5)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
CN104504533A (en) * 2015-01-05 2015-04-08 用友医疗卫生信息***有限公司 Medical system establishing method and medical system establishing device
CN104537250A (en) * 2015-01-05 2015-04-22 用友医疗卫生信息***有限公司 Medical data storage method and device
CN105205334A (en) * 2015-10-11 2015-12-30 张姬娟 Doctor-patient data processing method
CN105335920A (en) * 2015-10-11 2016-02-17 张姬娟 Patient data processing method
WO2017157033A1 (en) * 2016-03-16 2017-09-21 苏州德品医疗科技股份有限公司 Smart ward information center system

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CN102968754A (en) * 2012-11-26 2013-03-13 中国联合网络通信集团有限公司 Method and equipment for establishing electronic medical record information

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Cited By (6)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
CN104504533A (en) * 2015-01-05 2015-04-08 用友医疗卫生信息***有限公司 Medical system establishing method and medical system establishing device
CN104537250A (en) * 2015-01-05 2015-04-22 用友医疗卫生信息***有限公司 Medical data storage method and device
CN104504533B (en) * 2015-01-05 2018-09-14 用友医疗卫生信息***有限公司 Medical system method for building up and medical system establish device
CN105205334A (en) * 2015-10-11 2015-12-30 张姬娟 Doctor-patient data processing method
CN105335920A (en) * 2015-10-11 2016-02-17 张姬娟 Patient data processing method
WO2017157033A1 (en) * 2016-03-16 2017-09-21 苏州德品医疗科技股份有限公司 Smart ward information center system

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