Electronic medical record and method and system for controlling medical process on the basis of same

Abstract

The invention discloses an electronic medical record and a method and a system for controlling the medical process on the basis of the same. The method for controlling the medical process comprises the following steps of: establishing a medical path form frame according to medical dates or times; setting identity columns for multi-layer information items inside the medical path form frame; inputting medical template items into the medical path form frame according to disease kinds; executing or regulating the medical template items, and then carrying out digital signature confirmation; and combining executed medical template information into the electronic medical record according to a specified format. The invention provides the method for controlling the medical process of a disease by adopting a standard clinical path for doctors, thereby ensuring the medical quality; and in addition, the invention records and manages the information of the medical process, thereby generating the electronic medical record.

Description

technical field [0001] The invention relates to an electronic medical record and an electronic medical record generating device in a computer system, as well as a method and a system for controlling a disease medical process based on the electronic medical record. Background technique [0002] When traditional medical service providers provide medical services to patients, they mainly act on the ability and experience of individual doctors. The knowledge background and experience of each doctor determine the quality and benefit of each medical event. Although hospitals and other institutions will pass training and formulate methods such as diagnosis and treatment routines to guide the medical behavior of individual doctors, but they cannot provide reference methods and corresponding prompts at any time during the medical process, so that individual doctors still rely mainly on habits and experience in actual operations; at the same time, different doctors There is no technic...

AI Technical Summary

Problems solved by technology

[0002] When traditional medical service providers provide medical services to patients, they mainly act on the ability and experience of individual doctors. The knowledge background and experience of each doctor determine the quality and benefit of each medical event. Although hospitals and other institutions will pass training and formulate methods such as diagnosis and treatment routines to guide the medical behavior of individual doctors, but they cannot provide reference methods and corresponding prompts at any time during the medical process, so that individual doctors still rely mainly on habits and experience in actual operations; at the same time, different doctors There is no technical means to objectively compare different medical methods, and it is impossible to judge their pros and cons. As a result, good medical methods cannot be promoted in time, and poor medical methods cannot be eliminated in time. Young doctors cannot avoid repeating mistakes and directly adopt good medical methods. methods, thereby affecting the quality and cost of medical care, which to a certain extent has caused the problem of expensive and difficult medical treatment; some governments or academic institutions hope to standardize doctors' medical behaviors by formulating clinical pathway standards, but these clinical pathway standards are based on written texts It can only rely on the memory and understanding of individual doctors to guide medical practice, and cannot guide doctors' medical behaviors in the clinical frontline; at present, electronic medical records are mainly generated by recording medical events afterwards, which is likely to cause omissions and inaccuracies. Without timely digital signatures for on-duty events, it is easy to be maliciously tampered with, and can no longer meet the needs of modern society

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