CN107391933A - A kind of electronic health record quality control management device and method - Google Patents
A kind of electronic health record quality control management device and method Download PDFInfo
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- CN107391933A CN107391933A CN201710607437.5A CN201710607437A CN107391933A CN 107391933 A CN107391933 A CN 107391933A CN 201710607437 A CN201710607437 A CN 201710607437A CN 107391933 A CN107391933 A CN 107391933A
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- electronic health
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- quality control
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- G—PHYSICS
- G06—COMPUTING; CALCULATING OR COUNTING
- G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
- G06Q10/00—Administration; Management
- G06Q10/06—Resources, workflows, human or project management; Enterprise or organisation planning; Enterprise or organisation modelling
- G06Q10/063—Operations research, analysis or management
- G06Q10/0639—Performance analysis of employees; Performance analysis of enterprise or organisation operations
- G06Q10/06395—Quality analysis or management
Abstract
The present invention proposes a kind of electronic health record quality control management device and method, and the device includes：Electronic health record collecting unit, electronic health record data resolution unit, link Quality Control unit and Online QC unit；Wherein, electronic health record collecting unit is used to gather electronic health record data message；Electronic health record data resolution unit is used to parse the data message, and carries out quality control to electronic health record for analysis result；Link Quality Control unit is used for the quality examination to having completed electronic health record；Online QC unit is used for the quality examination to electronic health record in completion.The present invention occurs diagnosis and treatment event-monitoring progress medical record writing for patient and given a previous notice, case history Quality control rules inspecting in process is carried out during medical record writing to remind, complete to carry out case history postmortem and scoring in quality control process in medical record writing, reflect the quality condition of electronic health record in time.
Description
Technical field
The invention belongs to the technical field that medical system is information-based, more particularly to a kind of quality control management of electronic health record
Device and method.
Background technology
Case history be doctor in long-term clinical practice flexibly use medical knowledge summary of experience, it is objective intactly
Have recorded the change of illness state of patient and the overall process of diagnosis and treatment, be medical worker formed during curative activity word, chart,
The summation of the data such as image, section.In information technology growing today, electronic medical record system is gradual in situation of all-level hospitals
Popularization, compares over traditional papery case history, electronic health record have the characteristics that writing is convenient, interact facilitate, access it is flexible, it
Appearance facilitates medical worker's writing and inquiry, improves operating efficiency, but also shows some medical record quality problems, and turns into
The important component of medical quality managent.With the deep application of electronic health record, new put down is provided for quality of case history control
Platform, the real-time Quality Control of electronic health record become possibility --- and how to manage electronic health record quality and have become hospital quality management
One new problem of department.
At present, there is very big limitation in electronic health record quality control system function.It is responsible for quality of case history control specially
Quality Control doctor still need the case history manually filled in clinician and carry out assessment inspection, cause quality control process efficiency
Low, processing procedure hysteresis, can not reflect quality of case history situation in time.
Based on this, electronic health record quality control management device and method provided by the invention is drawn by embedded Online QC
Hold up, it is automatic to parse Quality Control standards of grading and Quality control rules, diagnosis and treatment event-monitoring progress medical record writing occurs for patient and carries in advance
Wake up, case history Quality control rules inspecting in process is carried out during medical record writing and is reminded, complete to carry out in quality control process in medical record writing
Case history postmortem and scoring, reflect the quality condition of electronic health record in time.
The content of the invention
The present invention is as follows to solve the technical scheme that above-mentioned technical problem proposes：
The present invention proposes a kind of electronic health record quality control management device, including：Electronic health record collecting unit, electronics disease
Count one by one according to resolution unit, link Quality Control unit and Online QC unit；Wherein, electronic health record collecting unit is used to gather electronics disease
Go through data message；Electronic health record data resolution unit is used to parse the data message, and for analysis result to electricity
Sub- case history carries out quality control；Link Quality Control unit is used for the quality examination to having completed electronic health record, including case history selective examination mould
Block, spot-check grading module and sampling result feedback module；Online QC unit is used for the quality examination to electronic health record in completion,
Including rule parsing module, task allocating module, operation inspection module.
Further, case history selective examination module is used to take out accordingly using the preset querying condition of described device and doctor's setting
Look into rule condition and extracted to having completed electronic health record；Grading module is spot-check to be used for automatically according to Quality control rules afterwards to extracting
Electronic medical record document enter line discipline inspection and scoring；Sampling result feedback module is used to this time is spot-check into the defects of finding automatically
Problem feeds back to the doctor of case history ownership, notifies doctor to carry out the case history rectification of associated disadvantages problem.
Further, rule parsing module is used for Quality control rules are parsed and run in advance and in thing；Task is distributed
Module is used for the generation according to operation case history patient's diagnosis and treatment dependent event, and the corresponding Quality control rules in advance of triggering in time simultaneously produce
Quality Control task reminders are to doctor before making trouble；Operation inspection module is used for according to operation case history on-line operation state, automatic running thing
In middle content Quality control rules, thing logic rules carry out parsing go forward side by side line discipline verification judge, so as to doctor in medical record writing mistake
On-line Tip is carried out in journey.
Further, the quality examination of link Quality Control unit includes medical record writing normalized checking and clinic diagnosis quality is examined
Look into, wherein, medical record writing normalized checking be used to judging deadline of case history, format write paragraph, medical terminology used whether
Meet preset rules；Clinic diagnosis quality examination is made the rounds of the wards including three-level, informed consent, anesthesia interview, diagnoses and treatment, auxiliary inspection
Look into, whether nosocomial infection and/or Antibiogics usage meet preset rules.
Further, data message includes structured electronic patient record data and the electronic health record data of natural language.
The invention also provides a kind of electronic health record quality control management method, comprise the following steps：
Step 1：Gather electronic health record data message；
Step 2：The data message is parsed；
Step 3：Relevant information is extracted for different data types；
Step 4：Electronic health record status is judged according to the relevant information；
Step 5：According to different conditions case history, the quality of electronic health record is controlled.
Further, data type different described in step 3 includes structured electronic patient record data and natural language
Electronic health record data.
Further, electronic health record state in which includes not carrying out, in progress, has completed.
Further, step 5 is specially：If electronic health record state in which not carry out, is entered to act to electronic health record
Preceding quality control；If electronic health record state in which is in carrying out, the quality control entered to electronic health record in acting；It is if electric
Sub- case history state in which then carries out quality control afterwards to have completed to electronic health record.
Further, the quality control in advance includes：Quality control rules in advance are parsed and run；According to operation
The generation of case history patient's diagnosis and treatment dependent event, the corresponding Quality control rules in advance is triggered in time and produce Quality Control task in advance carrying
Wake up to doctor；
Further, the quality control in the thing includes：According to operation case history on-line operation state, in automatic running thing
In content Quality control rules, thing logic rules carry out parsing go forward side by side line discipline verification judge, so as to doctor in medical record writing process
Middle carry out On-line Tip.
Further, the quality control afterwards includes：Extracted to having completed electronic health record；Automatically according to afterwards
Quality control rules enter line discipline inspection and scoring to the electronic medical record document of extraction；Automatically it is anti-the defects of finding problem to be spot-check into this time
The doctor of the case history of feeding ownership, doctor is notified to carry out the case history rectification of associated disadvantages problem.
The advantage of the invention is that：Quality control in advance, in thing, afterwards can be carried out to electronic health record, and to electronics
The processing of the data message of case history has compatibility, not only with processing structure electronic health record data but also can handle nature language
The electronic health record data of speech, reflect the quality condition of electronic health record in time.
Brief description of the drawings
By reading the detailed description of hereafter preferred embodiment, it is various other the advantages of and benefit it is common for this area
Technical staff will be clear understanding.Accompanying drawing is only used for showing the purpose of preferred embodiment, and is not considered as to the present invention
Limitation.And in whole accompanying drawing, identical part is denoted by the same reference numerals.In the accompanying drawings：
Fig. 1 is a kind of electronic health record quality control management apparatus structure schematic diagram of the present invention.
Fig. 2 is the electronic health record quality control management method flow diagram of the present invention.
Embodiment
The illustrative embodiments of the disclosure are more fully described below with reference to accompanying drawings.Although this public affairs is shown in accompanying drawing
The illustrative embodiments opened, it being understood, however, that may be realized in various forms the disclosure without the reality that should be illustrated here
The mode of applying is limited.Conversely, there is provided these embodiments are to be able to be best understood from the disclosure, and can be by this public affairs
The scope opened completely is communicated to those skilled in the art.
Fig. 1 is a kind of electronic health record quality control management apparatus structure schematic diagram of the present invention.Fig. 2 is electronics of the present invention disease
Go through quality control management method flow diagram.The embodiment of the present invention is illustrated with reference to Fig. 1 and Fig. 2.
As shown in figure 1, a kind of electronic health record quality control management device of the present invention includes electronic health record collecting unit, electricity
Sub- medical record data resolution unit, link Quality Control unit and Online QC unit.
Wherein, electronic health record collecting unit is used to obtain electronic health record data.
The electronic health record data got enter electronic health record data resolution unit, electronic health record data resolution unit pair
Acquired electronic health record data are parsed, and obtain the type of data message.The electronic health record data can be structuring
The data of electronic health record, or the electronic health record data of natural language.
If the electronic health record is the data of structured electronic patient record, the electronic health record data are with metadata
The set of patient information in structured electronic patient record, metadata specifically include symptom metadata, anatomical site metadata, when
Between metadata, quantity metadata, logic judgment metadata etc., such as " diarrhoea " belongs to symptom metadata.
If the electronic health record is the electronic health record data of natural language, the electronic health record data are with chapters and sections
The set of patient information in electronic health record, the relevant information of case history can be obtained by extracting keyword from chapters and sections.
After the data message for obtaining electronic health record, you can carry out management and control to the quality of electronic health record.
According to the data message of above-mentioned electronic health record, electronic health record state in which can be judged, such as above-mentioned data
Information is complete, then judges that the electronic health record for completion status, starts the quality control afterwards to case history；If above-mentioned number
It is believed that some module or be all blank in breath, then judge the part of the electronic health record or electronic health record not carry out
State, start the quality control in advance to case history；If in above-mentioned data message some module or all existing partial datas but
It is imperfect, then judges the part of the electronic health record or electronic health record for state in carrying out, start matter in the thing to case history
Amount control.
If carrying out quality control afterwards to case history, start link Quality Control unit, link Quality Control unit is spot-check including case history
Module, spot-check grading module and sampling result feedback module.
Case history selective examination module is used to spot-check regular bar accordingly using the preset querying condition of described device and doctor's setting
Part extracts to having completed electronic health record；Quality Control doctor can utilize some preset querying conditions first, and setting is accordingly
Rule condition is spot-check, currently will be found (such as in institute typical case case history tabulation：Today inpatient, operation patients today, be critically ill
Seriously ill patient history, critically ill patient case history etc.).Doctor will go to following each section office to go to look into the typical case history of extraction in the past, now logical
The selective examination case history inquiry of link Quality Control unit is crossed, the case history for meeting link Quality Control selective examination requirement can be listed and recommend Quality Control
Doctor.The case history list that Quality Control personnel inquire about in corresponding selective examination, certain case history is chosen, click is spot-check, and the case history is just entered
Enter in selective examination case history list.Quality Control personnel can select case history in certain selective examination list, click on selective examination button, be put into link matter
Control selective examination case history working interface, then, the electronic medical record document bibliographic structure tree that user can click on working interface sees this part
The electronic medical record document that case history has had, double-click can recall the case history document and be checked.
Selective examination grading module is used to enter line discipline inspection to the electronic medical record document of extraction automatically according to Quality control rules afterwards
And scoring；When progress case history is checked, Quality Control doctor can click on the selective examination scoring function of module offer, ejection
Selective examination scoring record window, in the window, module will check that standards of grading point list defect scoring list according to quality of case history, so
Afterwards Quality Control doctor can typing wherein selective examination find the defects of, can be automatically according to Quality control rules to corresponding in defect list system
Case history document enter line discipline inspection and meanwhile be also listed in the defects of will be seen that scoring list allow Quality Control doctor refer to.Quality Control doctor
Scoring content can be preserved, change, delete.Inspection for link quality includes medical record writing normalized checking and clinic
Diagnosis and treatment quality examination.Inspection scoring can be carried out for medical record writing normalized checking according to medical record writing standards of grading；For facing
Bed diagnosis and treatment inspection be mainly three-level make the rounds of the wards, informed consent, anesthesia interview, diagnoses and treatment, auxiliary examination, nosocomial infection, antimicrobial
Thing using etc. carry out selective examination scoring.
The defects of sampling result feedback module is used to this time is spot-check into discovery automatically problem feeds back to the doctor of case history ownership
It is raw, notify doctor to carry out the case history rectification of associated disadvantages problem.After Quality Control doctor completes the selective examination of certain part of case history document,
Complete link Quality Control selective examination scoring.At this moment selective examination is clicked on to complete.This point of case history can be put into by module have been spot-check case history list and has gone through
Shi Zhong.Meanwhile this time can be spot-check into the defects of finding problem automatically and fed back at the doctor of case history ownership, notify doctor to carry out
The case history rectification of associated disadvantages problem.
If case history is carried out in advance or quality control in thing, startup Online QC unit, Online QC unit include rule
Then parsing module, task allocating module, operation inspection module.
Rule parsing module is used for Quality control rules are parsed and run in advance and in thing；
Task allocating module is used for the generation according to operation case history patient's diagnosis and treatment dependent event, and triggering in time is corresponding described
In advance Quality control rules and produce in advance Quality Control task reminders to doctor；Such as prompt which project doctor should fill in.
Operation inspection module is used for according to operation case history on-line operation state, content Quality control rules, thing in automatic running thing
Middle logic rules carry out parsing go forward side by side line discipline verification judge, to carry out On-line Tip during medical record writing to doctor；
Such as during doctor writes case history, the specification medical terminology prompting of correlation, or automatic error-correcting etc. are provided.
Based on above-mentioned electronic health record quality control management device and method, diagnosis and treatment event-monitoring occurs for patient and carries out
Medical record writing is given a previous notice, and case history Quality control rules inspecting in process is carried out during medical record writing and is reminded, is completed in medical record writing
Case history postmortem and scoring are carried out in quality control process, reflects the quality condition of electronic health record in time, and electronic health record need not
Structured electronic patient record is necessary for, quality control management can also be completed to the electronic health record of natural language, system compatibility is good.
The foregoing is only a preferred embodiment of the present invention, but protection scope of the present invention be not limited thereto,
Any one skilled in the art the invention discloses technical scope in, the change or replacement that can readily occur in,
It should all be included within the scope of the present invention.Therefore, protection scope of the present invention should be with the protection model of the claim
Enclose and be defined.
Claims (10)
- A kind of 1. electronic health record quality control management device, it is characterised in that：Including：Electronic health record collecting unit, electronic health record Data resolution unit, link Quality Control unit and Online QC unit；Wherein,The electronic health record collecting unit is used to gather electronic health record data message；The electronic health record data resolution unit is used to parse the data message, and for analysis result to electronics disease Go through carry out quality control；The link Quality Control unit is used for the quality examination to having completed electronic health record, including case history selective examination module, selective examination scoring Module and sampling result feedback module；The Online QC unit is used for the quality examination to electronic health record in completion, including rule parsing module, task distribution Module, operation inspection module.
- 2. electronic health record quality control management device as claimed in claim 1, it is characterised in that：Wherein,The case history selective examination module is used to spot-check regular bar accordingly using the preset querying condition of described device and doctor's setting Part extracts to having completed electronic health record；The selective examination grading module is used to enter line discipline inspection to the electronic medical record document of extraction automatically according to Quality control rules afterwards And scoring；The defects of sampling result feedback module is used to this time is spot-check into discovery automatically problem feeds back to the doctor of case history ownership It is raw, notify doctor to carry out the case history rectification of associated disadvantages problem.
- 3. electronic health record quality control management device as claimed in claim 1, it is characterised in that：The rule parsing module is used In to Quality control rules are parsed and run in advance and in thing；The task allocating module is used for the generation according to operation case history patient's diagnosis and treatment dependent event, and triggering in time is corresponding described In advance Quality control rules and produce in advance Quality Control task reminders to doctor；The operation inspection module is used for according to operation case history on-line operation state, content Quality control rules, thing in automatic running thing Middle logic rules carry out parsing go forward side by side line discipline verification judge, to carry out On-line Tip during medical record writing to doctor.
- 4. electronic health record quality control management device as claimed in claim 2, it is characterised in that：The link Quality Control unit Quality examination includes medical record writing normalized checking and clinic diagnosis quality examination, wherein,The medical record writing normalized checking be used to judging deadline of case history, format write paragraph, medical terminology used whether Meet preset rules；The clinic diagnosis quality examination is made the rounds of the wards including three-level, informed consent, anesthesia interview, diagnoses and treatment, auxiliary examination, in institute Whether infection and/or Antibiogics usage meet preset rules.
- 5. electronic health record quality control management device as claimed in claim 1, it is characterised in that：The data message includes knot The electronic health record data of structure electronic health record data and natural language.
- A kind of 6. electronic health record quality control management method, it is characterised in that：Comprise the following steps：Step 1：Gather electronic health record data message；Step 2：The data message is parsed；Step 3：Relevant information is extracted for different data types；Step 4：Electronic health record status is judged according to relevant information；Step 5：According to different conditions case history, the quality of electronic health record is controlled.
- 7. electronic health record quality control management method as claimed in claim 6, it is characterised in that：Described in the step 3 not Same data type includes structured electronic patient record data and the electronic health record data of natural language.
- 8. electronic health record quality control management method as claimed in claim 7, it is characterised in that：Electronic health record state in which Including not carrying out, neutralized and completed.
- 9. electronic health record quality control management method as claimed in claim 8, it is characterised in that：The step 5 is specially： If not carry out, quality control in advance is carried out to electronic health record for electronic health record state in which；If residing for electronic health record State for carry out in, then to electronic health record enter act in quality control；If electronic health record state in which is has completed, right Electronic health record carries out quality control afterwards；The quality control in advance includes：Quality control rules in advance are parsed and transported OK；According to the generation of operation case history patient's diagnosis and treatment dependent event, the corresponding Quality control rules in advance of triggering in time simultaneously produce thing Preceding Quality Control task reminders are to doctor；According to operation case history on-line operation state, patrolled in automatic running thing in content Quality control rules, thing Volume rule carries out parsing line discipline verification of going forward side by side and judged, to carry out On-line Tip during medical record writing to doctor.
- 10. electronic health record quality control management method as claimed in claim 9, it is characterised in that：The quality control afterwards System includes：Extracted to having completed electronic health record；The electronic medical record document of extraction is carried out automatically according to Quality control rules afterwards Rule checks and scoring；Automatically the defects of this time being spot-check into discovery problem feeds back to the doctor of case history ownership, notifies doctor to enter The case history rectification of row associated disadvantages problem.
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| CN108389606A (en) * | 2018-05-08 | 2018-08-10 | 灵玖中科软件（北京）有限公司 | A kind of the data quality control system and its control method of electronic medical record homepage |
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| CN110299196A (en) * | 2019-07-01 | 2019-10-01 | 首都医科大学附属北京胸科医院 | Check method, device and the computer readable storage medium of patient data |
| CN110600095A (en) * | 2019-08-23 | 2019-12-20 | 和宇健康科技股份有限公司 | Quality control method and system for electronic medical record |
| CN110751994A (en) * | 2019-08-28 | 2020-02-04 | 云知声智能科技股份有限公司 | Differential display method and system for medical record template |
| CN110808089A (en) * | 2019-10-16 | 2020-02-18 | 云知声智能科技股份有限公司 | Method and device for displaying defect number under document catalog |
| CN110826851A (en) * | 2019-09-25 | 2020-02-21 | 云知声智能科技股份有限公司 | Quality control method and device |
| CN111180033A (en) * | 2019-12-31 | 2020-05-19 | 云知声智能科技股份有限公司 | Defect document display method and device |
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| CN111967241A (en) * | 2020-09-03 | 2020-11-20 | 卫宁健康科技集团股份有限公司 | Medical record writing quality control method and system |
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| CN108389606A (en) * | 2018-05-08 | 2018-08-10 | 灵玖中科软件（北京）有限公司 | A kind of the data quality control system and its control method of electronic medical record homepage |
| CN109671478A (en) * | 2018-12-24 | 2019-04-23 | 天津阿贝斯努科技有限公司 | Clinical test case report form quality control system and method for quality control |
| CN110299196A (en) * | 2019-07-01 | 2019-10-01 | 首都医科大学附属北京胸科医院 | Check method, device and the computer readable storage medium of patient data |
| CN110600095A (en) * | 2019-08-23 | 2019-12-20 | 和宇健康科技股份有限公司 | Quality control method and system for electronic medical record |
| CN110751994A (en) * | 2019-08-28 | 2020-02-04 | 云知声智能科技股份有限公司 | Differential display method and system for medical record template |
| CN110751994B (en) * | 2019-08-28 | 2022-04-01 | 云知声智能科技股份有限公司 | Differential display method and system for medical record template |
| CN110826851A (en) * | 2019-09-25 | 2020-02-21 | 云知声智能科技股份有限公司 | Quality control method and device |
| CN110826851B (en) * | 2019-09-25 | 2022-04-01 | 云知声智能科技股份有限公司 | Quality control method and device |
| CN112582050A (en) * | 2019-09-29 | 2021-03-30 | 上海市嘉定区南翔医院 | Intelligent monitoring system and method |
| CN112582040A (en) * | 2019-09-29 | 2021-03-30 | 上海市嘉定区南翔医院 | Intelligent data monitoring system and method for medical record quality control |
| CN110808089B (en) * | 2019-10-16 | 2022-04-01 | 云知声智能科技股份有限公司 | Method and device for displaying defect number under document catalog |
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