System for generating structured electronic medical record

Abstract

The invention discloses a system for generating a structured electronic medical record. The system is characterized by comprising symptom and sign dictionaries, a field conjunction management module, a medical record modification module and a medical record writ generating module. The multiple symptom and sign dictionaries are provided for selection by a doctor, different symptom and sign dictionaries are configured for different departments, each symptom and sign dictionary exists in a field mode, and the content of each field is a symptom and sign dictionary module in a structured point-and-click mode; according to the field conjunction management module, multiple conjunctions and punctuation marks are provided, the conjunctions and / or the punctuation marks are added in front and / or behind the fields in the selected symptom and sign dictionaries to form a field conjunction management module of a fluent medical record language; the medical record modification module is used for providing an interface for modifying the medical record by the doctor; the medical record document generating module is used for generating and displaying a final medical record document. The system has the advantages that a lot of time is saved for medical workers, and better services are provided for a hospital and patients; the proof capacity for a medical dispute is improved; the normalization of the medical record is improved; first-hand and valuable documents are provided for scientific research, teaching and statistic analysis.

Description

technical field [0001] The invention relates to a system for generating electronic medical records, in particular to a system for generating structured electronic medical records, belonging to the technical field of computers. Background technique [0002] With the popularization of computer technology, major hospitals are vigorously developing electronic medical records. At present, the most used electronic medical records are non-structured electronic medical records (Non-Structured EMR). In the unstructured electronic medical record system, except for tabular data, all medical documents are saved in the database in the form of text entry. [0003] It has been found through practice that the existing unstructured electronic medical records have the following deficiencies: [0004] 1. When medical personnel form electronic medical records, they still have to input word by word. Although the work efficiency is higher than that of handwriting, due to the process of thinking ...

AI Technical Summary

Problems solved by technology

[0004] 1. When medical personnel form electronic medical records, they still have to input word by word. Although the work efficiency is higher than that of handwriting, due to the process of thinking and revision, the work efficiency needs to be further improved;

[0005] 2. Due to the different habits of doctors, the degree of standardization of medical records needs to be improved

However, the structured electronic medical records based on form templates also have some disadvantages: since the content of medical records is generated by clicking, the flexibility of clinicians is reduced, and content cannot be added or deleted at will.

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