Quality control method and device for electronic medical records

Abstract

The invention discloses quality control method and device for electronic medical records. The method comprises the following steps of obtaining a medical record check rule set by a user; and analyzing the medical record appointed by the user according to the medical record check rule, and outputting the analysis result. The device comprises a rule acquiring module and a medical record analyzing module. The invention can perform quality check on the electronic medical records according to the medical record check rule appointed by the user, effectively enhance the efficiency of the electronic medical record check, and improve the accuracy and reliability of the electronic medical records.

Description

Technical field [0001] The invention relates to the field of quality control of electronic medical records, in particular to a method and device for quality control of electronic medical records. Background technique [0002] The medical record is the file that records all the patients’ medical visits. It is the most intuitive information obtained by medical staff through outpatient, physical examination, auxiliary examination, diagnosis, treatment, and nursing activities. Especially with the development of computer technology, electronic medical records have Become an important form of medical records. Since medical records are used by hospitals to evaluate patients or make targeted diagnosis of patients’ health, the requirements for medical records are high. The quality of medical records directly affects the hospital’s diagnosis of patients’ health, while electronic medical records involve a large number of records. Paste, copy and other operations, therefore, how to check or...

AI Technical Summary

Problems solved by technology

[0003] Because medical records need to record a large amount of medical information about patients, and in the process of making electronic medical records, due to staff mistakes or other reasons, it is easy to cause errors in medical records, which will affect the authenticity and reliability of medical records. There are many requirements for medical information recorded in medical records, such as requirements for time, requirements for the order of recorded information, and requirements for recorded content. Quality control is more difficult

At present, the quality control of electronic medical records is generally carried out in the form of manual random checks, that is, according to the form of manual random checks of medical records, check whether there are missing fillings, wrong fillings, or fillings that obviously do not meet the regulations, etc., to judge the quality of the medical records. In this way, the quality control of medical records is carried out in the form of random inspection, and it is impossible to check all the large number of electronic medical records, so it is impossible to achieve the effect of controlling electronic medical records, and the inspection is carried out manually, which will inevitably increase the workload of manual work, and human factors The effect of also reduces the accuracy of QA

In addition, in the prior art, there is also a quality control rule for the specific disease formulated according to each specific disease, that is, the medical records of the specific disease are checked according to the formulated rules, but this method can only be used for Specifically, medical records are checked, and its applicability is poor. Due to the large number of electronic medical records recorded in hospitals, there are many types of different diseases, and different medical records are checked differently. This method cannot effectively control the accuracy of electronic medical records. sex and reliability

[0004] To sum up, in the prior art electronic medical record quality control, the quality control of electronic medical records is carried out in the form of manual spot check, which requires a lot of waste of manpower, and the effect of quality control is poor, and the quality control of the entire electronic medical record cannot be controlled by spot check. , the efficiency of electronic medical record inspection is low

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