CN107563127A - The rapid generation and system of a kind of electronic health record - Google Patents
The rapid generation and system of a kind of electronic health record Download PDFInfo
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- CN107563127A CN107563127A CN201711026175.XA CN201711026175A CN107563127A CN 107563127 A CN107563127 A CN 107563127A CN 201711026175 A CN201711026175 A CN 201711026175A CN 107563127 A CN107563127 A CN 107563127A
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Abstract
The invention discloses a kind of rapid generation of electronic health record and system, methods described includes：According to the demand of user, multiple case history modules are established, according to selection of the user to the case history module, medical record templates corresponding to formation；Editor of the user to medical record templates is received, forms electronic health record.The present invention forms medical record templates by case history modularization, according to the corresponding case history module of the Selection and call of user, passes through the simple editor to required medical record templates, you can quickly generate electronic health record, the writing electronic health record that can assist a physician quick, accurate and effective.
Description
Technical field
The present invention relates to the rapid generation and system of electronic health record technical field, more particularly to a kind of electronic health record.
Background technology
In face of the increasing of aging population and patient populations, the work that clinicians write case history is more and more numerous
Weight, this just needs a set of efficient electronic health record generation system, clinician can just solved from heavy medical record writing work
Take off.
The electronic medical record system of early stage, most of design for medical record templates lack unified specification and standard, content
With the inadequate specification of form, not electronic health record mould is aimed at using the document editors such as word processor WORD, these softwares more
Plate and design, often have various function restrictions, it is impossible to meet clinical position demand.Therefore, such electronic health record system
System is gradually eliminated.
In recent years, the electronic medical record system based on expandable mark language XML exploitation has occurred, the electronics disease of relatively early stage
It is more convenient, more convenient to go through system.At present, the electronic medical record system based on XML exploitations, by designing medical record templates editing machine, makes
Doctors, according to specialty, the difference of disease, freely set various medical record templates (such as using template tool：Will, first in hospital
Progress note, discharge record etc.), and can be deposited into template library, when writing case history, call which template to generate accordingly
Electronic health record content, reach the effect of What You See Is What You Get.Ask although part that the above method preferably resolves medical record writing
Topic, but still can not be flexible, quick, accurate and effective reply Electronic Medical Record in various complicated situations.
The content of the invention
For in the prior art the defects of, the present invention provides a kind of rapid generation and system of electronic health record, can gram
The defects of taking in the prior art, the writing electronic health record for assisting a physician quick, accurate and effective.
In a first aspect, the invention provides a kind of rapid generation of electronic health record, methods described includes：
According to the demand of user, multiple case history modules are established；
According to selection of the user to the case history module, medical record templates corresponding to formation；
Editor of the user to medical record templates is received, forms electronic health record.
Further, the demand according to user, multiple case history modules is established, are specifically included：
According to the content that perhaps prestored in user's input, multiple case history modules are established；
By module editing interface, edlin is entered to multiple case history modules of foundation.
Further, the case history module includes module title and module contents.
Further, multiple case history modules of described pair of foundation enter edlin, specifically include following set and operate：
Set whether by the case history module creation be follow-up case history linked source；
Whether set using the case history module as content of conducting a compulsory examination；
After being arranged on generation electronic health record, the case history module is not as applied to, if hides the module automatically.
Further, multiple case history modules of described pair of foundation enter edlin, in addition to：Added in the case history module of part
At least one submodule.
Further, according to selection of the user to the case history module, medical record templates corresponding to formation, specifically include：Connect
At least one keyword of user's input is received, searches for the case history module of correlation automatically according to the keyword.
Further, editor of the user to medical record templates is received, electronic health record is formed, specifically includes：User is received to institute
Supplement, modification and the preservation operation of medical record templates are stated, forms the electronic health record that can be matched with actual conditions.
Second aspect, present invention also offers a kind of rapid generation of electronic health record, methods described includes：
First in use, establishing multiple case history modules, and multiple case history modules are carried out with different combinations, form multiple diseases
Go through template；User is received to the selection operation of medical record templates, calls corresponding medical record templates, and to the phase in the medical record templates
Close case history module and enter edlin；
When identical case history module is used subsequently in other medical record templates, the volume according to user to foregoing case history module
Volume, the content of the case history module after AutoLink editor, form follow-up electronic health record.
The third aspect, present invention also offers a kind of quick-speed generation system of electronic health record, the system includes：Module is given birth to
Into unit, template generation unit, case history generation unit；
The module generation unit, for establishing multiple case history modules；
The template generation unit, for according to selection of the user to the case history module, medical record templates corresponding to formation；
The case history generation unit, for the editor according to user to medical record templates, form electronic health record.
As shown from the above technical solution, the present invention provides a kind of rapid generation and system of electronic health record, by case history
Modularization, medical record templates are formed according to the corresponding case history module of the Selection and call of user, pass through the simple volume to medical record templates
Volume, you can electronic health record is quickly generated, the writing electronic health record that can assist a physician quick, accurate and effective.
Brief description of the drawings
Fig. 1 is the schematic flow sheet of the rapid generation for the electronic health record that the embodiment of the present invention one provides.
Fig. 2 is the schematic diagram of module editing interface.
Fig. 3 is that part of module double-clicks submodule display schematic diagram after opening in electronic health record template.
Fig. 4 is the module editing interface schematic diagram entered to case history module after edlin.
Fig. 5 is the detailed interface schematic diagram of the content of display case history module.
Fig. 6 is the interface schematic diagram of display keyword menu.
Fig. 7 is the search result schematic diagram by keyword search.
Fig. 8 is interface schematic diagram when being edited again to module or submodule content.
Fig. 9 is the schematic diagram that user selects corresponding case history module or submodule according to actual conditions.
Figure 10 is the schematic diagram of the electronic health record after storage.
Figure 11 is the schematic flow sheet of the rapid generation for the electronic health record that the embodiment of the present invention two provides
Figure 12 is the structural representation of the quick-speed generation system of electronic health record provided by the invention.
Embodiment
The embodiment of technical solution of the present invention is described in detail below in conjunction with accompanying drawing.Following examples are only used for
Clearly illustrate technical scheme, therefore be intended only as example, and the protection of the present invention can not be limited with this
Scope.
Embodiment one
Fig. 1 shows the schematic flow sheet of the rapid generation for the electronic health record that the embodiment of the present invention one provides.Such as Fig. 1
Shown, methods described includes：
Step S110, according to the demand of user, establish multiple case history modules.
Step S111, according to the content that perhaps prestored in user's input, multiple case history modules are established, each case history module is equal
With module title and module contents.
Wherein, user is mainly the medical personnels such as doctor, nurse, and the content and the content that prestores of user's input include medical science
The contents such as knowledge, state of an illness description.
Above-mentioned case history module includes patient information generic module, medical inspection generic module, disease specific module etc., wherein,
In the modules such as patient information generic module, medical inspection generic module, its module contents only includes basic framework, without other specific
Content；In disease specific module, its module contents is retouched including the state of an illness corresponding with the module title, comparatively detailed
State, user can supplement, and can delete unwanted content.
For example, the case history module of one " patient information " is established, due to information such as everyone sex, age, main suits not
It is identical to the greatest extent, therefore the basic frameworks such as sex, age, main suit are only listed in its module contents, particular content is by user above-mentioned
Voluntarily supplemented on the basis of basic framework；The case history module of one entitled " electrocardiogram " and for example is being established, due to everyone
The inspection result of electrocardiogram is different, and sinus rhythm, heart rate and its unit " beat/min ", normal or not just have been listed in the module
Basic framework is often waited, without enumerating specific hrv parameter, specific hrv parameter and other inspection results, is existed by user
Voluntarily supplemented according to common Electrocardiogram Feature type on the basis of above-mentioned basic framework；And for example, establish one it is entitled " acute
The medical record templates of the progress note of myocardial infarction-first ", there is acute myocardial infarction AMI more detailed under " present illness history " module in the template
State of an illness description, in the case where the state of an illness matches completely, user can directly use the module, in the case of Incomplete matching,
User can make appropriate delete.
Wherein, module title can be sentence, phrase, word, punctuation mark etc., and unlimited number of words.
Step S112, by module editing interface, edlin is entered to multiple case history modules of foundation.Module editor circle
Face is as shown in Figure 2.
Preferably, step S112, which specifically includes, carries out following setting operation to each case history module：Whether set by the mould
Block is created as the linked source of follow-up case history；For the content for needing extra care or easily malfunctioning, if the module is arranged to
Conduct a compulsory examination content；After generating electronic health record, module contents is not as applied to, if hides the module.In editing interface, each
There are the two options for user selections of "Yes" and "No" in setting option.
Wherein, by the case history module creation edited for follow-up case history linked source after, in the writing of follow-up case history, meeting
Enter the module and to the module in case history (for follow-up case history) above the content of edlin, AutoLink
Into follow-up case history.
Wherein, if being arranged to conduct a compulsory examination, the module will be displayed as particular color.The function of conducting a compulsory examination is applied to certain
A little special circumstances, the situation for such as needing the situation of extra care when writing case history or easily malfunctioning.For example, there is the heart in certain patient
Restrain not normal, heart rate is inconsistent with pulse rate, in order to remind doctor, corresponding case history module is arranged to conduct a compulsory examination, and sets
The case history module is shown in red afterwards.In medical record writing, double-click that confirm or edit can after the module contents of the case history module
The module is crossed, continues medical record writing below.
Wherein, if hidden module title, acquiescence are automatic to hide after electronic health record is generated after selection generation electronic health record
The module.Open and specific markers are used at the module title of automatic hidden function, it is automatic hidden module at this to prompt user.
Its application scenarios as shown in figure 3, auxiliary examination paragraph by tri- electrocardiogram, troponin, NT-proBNP module groups
Into, it is generally the case that Electrocardioscopy a few minutes can be finished, and troponin and NT-proBNP inspection results come out compared with
Slowly, the inspection result of usual typing out when writing progress note first, if troponin and NT-proBNP inspections
The fruit that comes to an end not yet obtains, then without typing, selection is automatic in this case hides, and after case history is preserved, then the module can be automatic
Hide, no longer show.In order to remind user that module opens hidden function, it is red that a deletion is shown as at its module
Line.But confirm or edit if user to the module double-click, then the module is no longer hidden.
The text box that both sides arrange in Fig. 3 is editor when entering edlin to module contents, is needed being clicked on mouse
After the case history module to be edited, the editor being shown, during without editing, not being shown.
Preferably, step S112 also includes：For part case history module, an at least submodule is added in the module.
By taking the Electrocardiogram Feature of acute myocardial infarction AMI this module as an example, because acute myocardial infarction AMI type is different, its Electrocardiogram Feature
Also differ, therefore under the module, corresponding submodule is added respectively for each type of acute myocardial infarction AMI.Addition
Submodule is shown in editing interface, and provides exercisable option, is available for user to search for and select.
Preferably, after submodule is added, edlin can be entered to the content detail of submodule, in addition, in order to faster
A certain submodule therein is searched for, can be that the submodule sets at least one keyword, for example, in above-mentioned acute myocardial infarction AMI
In one of submodule of this module of Electrocardiogram Feature, keyword " Non-ST Elevation Acute " is set, in the more feelings of submodule
We can pass through the keyword fast search to corresponding submodule and its content under condition.
Interface after being edited by step S112 is as shown in Figure 4.
Step S120, the selection operation according to user to the case history module, corresponding case history module is called, form case history
Template.
Specifically, user can force according to the actual conditions of patient in above-mentioned multiple case history modules particular without setting
In the module of inspection, the case history module needed, or user is selected independently to establish required module, above-mentioned case history module is common
Medical record templates corresponding to composition.
When user continuously have selected multiple case history modules, the punctuation mark specified is automatically generated, is marked in two case histories
Between module, the medical record templates space of a whole page to be formed is set to understand, in order.Similarly, when user continuously selects multiple submodule, also may be used
The punctuation mark specified is automatically generated among submodule.
Selection case history module can be accomplished by the following way：Consulted one by one in multiple case history modules of module library, from
Case history module needed for middle selection, but the workload of which is larger；It can also be realized by following function of search：By at least
Case history module needed for one keyword search, if more than one case history module is searched after input keyword, from what is searched
The module that needs is selected in case history module or inputs other keywords again scope is gradually reduced.Wherein, the search of keyword is with logical
The keyword that step 112 is configured is crossed to be defined, in the case where not setting keyword, the keyword that can be automatically extracted with system
It is defined.
In addition to above-mentioned case history module is called, the submodule under case history module can be also called according to the actual conditions of patient, is adjusted
It may be accomplished by with mode：Submodule therein is consulted one by one in case history module, as shown in figure 5, cursor is put
Consulted in submodule region, its automatic display content is detailed, so as to understand the submodule whether be needed for user, especially for
The detailed situation of the limited content that can not show submodule simultaneously of display interface.
If the quantity of submodule exceedes the displayable quantity of display interface, method of calling can also be real in the following manner
It is existing：Receive user and pass through the keyword that is inputted in keyword search frame；Or as shown in fig. 6, receive user cursor positioning, when with
When family positions cursor to search box, the automatic menu shown by the step S112 keywords pre-set, if user is aobvious
Selected therein at least one at least one keyword shown, then the keyword selected according to user is searched automatically
Rope.
For example, after user selectes " Non-ST Elevation Acute " this keyword, then can filter out all with " Non-ST Elevation Acute "
For the submodule of keyword, after search result is as shown in fig. 7, click on determination, the content of above-mentioned selected submodule will be with text
Form is shown in medical record templates.
Preferably, the module being shown in medical record templates includes word segment and edit symbol, and user can be right as needed
They are edited again.Wherein, edit symbol can be a pair of brackets of word segment correspondence, right angle quotation marks " " or other
Symbol, edit symbol represent that this section of word segment is a module, can help user's clear and definite current state faster, Yong Huru
It need to again edit, cursor can be moved to textual portions direct editing, the module can also be double-clicked, in the as shown in Figure 8 of ejection
Window in select required submodule to be edited again.
The medical record templates formed by step 120 are as shown in figure 9, the text box that both sides arrange in figure is to module contents
Enter editor during edlin, after the case history module for needing to edit is clicked on mouse, the editor can be shown, without compiling
When collecting, do not show.
Step S130, the editor according to user to medical record templates, form electronic health record.
The medical record templates of generation because its can not be completely with patient situation match, largely can not be directly as electronics
Case history by step S130 using, it is necessary to the edit operation such as further supplemented medical record templates, changed, being preserved, formation energy
The electronic health record that enough and patient profiles match.For example, supplement what is do not had in the personal information of patient, template in medical record templates
Other specific symptoms, doctor in charge's signature etc., describe to carry out to the symptom or the state of an illness with the actual state of an illness not being consistent in medical record templates
Modification.Because there is the basis of medical record templates, modification now is generally only simple modification, reduces the workload of user.Supplement,
After the completion of modification, click on and preserve or determine, you can store the electronic health record.
If the medical record templates of generation can match completely with patient profiles, supplemented and changed without user, can be direct
Click on and preserve or determine, complete the operation of storage electronic health record.Such a situation occurs in the follow-up case history of same patient.
Click on after preserving or determining, the edit symbol in medical record templates is hidden automatically, represents that this section of word segment is currently
Storage state.Assuming that grey parts are content needed for user in Fig. 9, the electronic health record after selecting and storing is as shown in Figure 10.
After storing electronic health record, the electronic health record can be shown or exported according to the operational order of user.
Based on above content, the technique effect that the embodiment of the present invention one can be realized is：By case history modularization, according to user
The corresponding case history module of Selection and call form medical record templates, pass through the simple editor to medical record templates, you can quickly generate
Electronic health record；Add it is autonomous create linked source, it is autonomous set conduct a compulsory examination, independently set whether hide inapplicable content, from
Punctuation mark, function of search etc. are automatically generated after dynamic display option full content, continuous selection；Assist a physician it is quick, accurate, have
The writing electronic health record of effect.
Embodiment two
Figure 11 shows the schematic flow sheet of the rapid generation for the electronic health record that the embodiment of the present invention one provides.Such as figure
Shown in 11, methods described includes：
Step S210, first in use, establishing multiple case history modules, and multiple case history modules are carried out with different combinations,
Form multiple medical record templates.
According to the medical knowledge perhaps to be prestored in user's input, multiple case history modules are established, each case history module has
There are module title and module contents；Its particular content is identical with the related content in embodiment one, repeats no more.
By module editing interface, edlin is entered to multiple case history modules of foundation.Module editing interface such as Fig. 2 institutes
Show；Its particular content is identical with the related content in embodiment one, repeats no more.
According to the difference of actual conditions such as patient, application scenarios, multiple case history modules are carried out with different combinations, is formed more
Individual specific medical record templates.For example, for patient medical first, group can be carried out through commonly used case history module to going to a doctor first
Close, form the medical record templates for being applied to medical patient first；, can be to further consultation through commonly used case history module for the patient of further consultation
It is combined, forms the medical record templates suitable for further consultation patient；For internal medicine, the case history module that can be often used to internal medicine is entered
Row combination, forms the medical record templates suitable for internal medicine.For specialist, required module can be independently established, generation is special
The medical record templates of section's disease.Generally speaking, medical record templates more refine, and need the content changed fewer after calling, generation electronics disease
The efficiency gone through is also higher.
Multiple specific medical record templates of formation are stored in ATL, called when in use according to actual conditions corresponding
Template, without being combined when participating in the cintest, the further generation for accelerating electronic health record.
Step S220, it is follow-up in use, reception user calls corresponding medical record templates to the selection operation of medical record templates；
Its invoked procedure is to calling case history module in the step S120 of embodiment one the step of is similar, repeats no more.
Step S230, editor of the user to the step S220 medical record templates called is received, form electronic health record；Its is specific
Content is identical with the related content in embodiment one, repeats no more.
Based on above content, the technique effect that the embodiment of the present invention two can be realized is：By case history modularization, by not
Same block combiner directly invokes the medical record templates of needs, and it is done simply into specific medical record templates in follow-up use
Editor, you can quickly generate electronic health record；Add autonomous establishment linked source, autonomous setting is conducted a compulsory examination, independently setting is
No hiding inapplicable content, automatic display option full content, automatically generate punctuation mark, function of search etc. after continuously selecting；
The writing electronic health record that can assist a physician quick, accurate and effective.
Embodiment three
To the embodiment of the present invention one accordingly, Figure 12 shows a kind of the quick of electronic health record provided in an embodiment of the present invention
The structural representation of generation system.As shown in figure 12, the system includes module generation unit 301, template generation unit 302,
Case history generation unit 303；Module generation unit 301, template generation unit 302, case history generation unit 303 are sequentially connected.
The module generation unit 301, for establishing multiple case history modules.Preferably, the module generation unit 301 is wrapped
Include module and establish subelement and module editor, module is established subelement and is used for according to the medical science perhaps to be prestored in user's input
Knowledge, multiple case history modules are established, each case history module is respectively provided with module title and module contents, wherein, module title can be with
It is sentence, phrase, word, punctuation mark etc., and unlimited number of words；Module editor is used to pass through module editing interface, to establishing
Multiple case history modules enter edlin, wherein, module editing interface is as shown in Figure 2.
It is further preferred that module editor is specifically used for carrying out each case history module following setting operation：Setting is
The no linked source by the module creation for follow-up case history；Whether setting conducts a compulsory examination to the module；After generating electronic health record,
Whether inapplicable module is hidden.There are the two options for user choosings of "Yes" and "No" in editing interface, in each setting option
Select.Module editor is additionally operable to：For part case history module, an at least submodule is added in the module.
The template generation unit 302, for the selection operation according to user to the case history module, call corresponding disease
Module is gone through, forms medical record templates.It is specifically used for：The selection operation of user is received, and according to the corresponding case history mould of the Selection and call
Block, form medical record templates.
The case history generation unit 303, for the editor according to user to medical record templates, form electronic health record.It is specific to use
In：User is received to edit operations such as the supplement of medical record templates, modification, preservations, forms the electricity that can be matched with patient profiles
Sub- case history.
Based on above content, what the embodiment of the present invention three can reach has the technical effect that：By case history modularization, according to user
The corresponding case history module of Selection and call form medical record templates, pass through the simple editor to medical record templates, you can quickly generate
Electronic health record；Add it is autonomous create linked source, it is autonomous set conduct a compulsory examination, independently set whether hide inapplicable content, from
Punctuation mark, function of search etc. are automatically generated after dynamic display option full content, continuous selection；Assist a physician it is quick, accurate, have
The writing electronic health record of effect.
Finally it should be noted that：Various embodiments above is merely illustrative of the technical solution of the present invention, rather than its limitations；To the greatest extent
The present invention is described in detail with reference to foregoing embodiments for pipe, it will be understood by those within the art that：Its according to
The technical scheme described in foregoing embodiments can so be modified, either which part or all technical characteristic are entered
Row equivalent substitution；And these modifications or replacement, the essence of appropriate technical solution is departed from various embodiments of the present invention technology
The scope of scheme, it all should cover among the claim of the present invention and the scope of specification.
Claims (9)
1. a kind of rapid generation of electronic health record, it is characterised in that methods described includes：
According to the demand of user, multiple case history modules are established；
According to selection of the user to the case history module, medical record templates corresponding to formation；
Editor of the user to medical record templates is received, forms electronic health record.
2. rapid generation according to claim 1, it is characterised in that the demand according to user, establish multiple
Case history module, is specifically included：
According to the content that perhaps prestored in user's input, multiple case history modules are established；
By module editing interface, edlin is entered to multiple case history modules of foundation.
3. rapid generation according to claim 2, it is characterised in that the case history module includes module title and mould
Block content.
4. rapid generation according to claim 2, it is characterised in that multiple case history modules of described pair of foundation are carried out
Editor, specifically include following set and operate：
Set whether by the case history module creation be follow-up case history linked source；
Whether set using the case history module as content of conducting a compulsory examination；
After being arranged on generation electronic health record, the case history module is not as applied to, if hides the module automatically.
5. rapid generation according to claim 4, it is characterised in that multiple case history modules of described pair of foundation are carried out
Editor, in addition to：An at least submodule is added in the case history module of part.
6. rapid generation according to claim 1, it is characterised in that according to choosing of the user to the case history module
Select, medical record templates corresponding to formation, specifically include：At least one keyword of user's input is received, according to the keyword certainly
The related case history module of dynamic search.
7. rapid generation according to claim 6, it is characterised in that receive user to the editor of medical record templates, shape
Into electronic health record, specifically include：User is received to the supplement of the medical record templates, modification and preserves operation, formation can be with reality
The electronic health record that border situation matches.
8. a kind of rapid generation of electronic health record, it is characterised in that methods described includes：
First in use, establishing multiple case history modules, and multiple case history modules are carried out with different combinations, form multiple case history moulds
Plate；User is received to the selection operation of medical record templates, calls corresponding medical record templates, and to the related diseases in the medical record templates
Go through module and enter edlin；
When identical case history module is used subsequently in other medical record templates, the editor according to user to foregoing case history module, from
The content of case history module after dynamic link editor, forms follow-up electronic health record.
9. a kind of quick-speed generation system of electronic health record, it is characterised in that the system includes：Module generation unit, template life
Into unit, case history generation unit；
The module generation unit, for the demand according to user, establish multiple case history modules；
The template generation unit, for according to selection of the user to the case history module, medical record templates corresponding to formation；
The case history generation unit, for the editor according to user to medical record templates, form electronic health record.
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| CN108831521A (en) * | 2018-05-25 | 2018-11-16 | 深圳医翼健康科技有限公司 | One kind being suitable for intelligent association system during electronic health record is filled in |
| CN111488730A (en) * | 2020-04-02 | 2020-08-04 | 重庆橡树信息科技有限公司 | Editor-based automatic generation method for single-disease electronic medical record |
| CN113035301A (en) * | 2019-12-25 | 2021-06-25 | 常州昊泽信息科技有限公司 | Intelligent medical record writing method based on big health data |
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| CN102509012A (en) * | 2011-11-04 | 2012-06-20 | 厦门市智业软件工程有限公司 | Method for mapping contents of electronic medical record into electronic medical record standard database |
| CN103559674A (en) * | 2013-11-25 | 2014-02-05 | 方正国际软件有限公司 | Structured entry device and method of medical record document |
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| CN113035301A (en) * | 2019-12-25 | 2021-06-25 | 常州昊泽信息科技有限公司 | Intelligent medical record writing method based on big health data |
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