Method and system for generating electronic case history with informing and signing functions

Abstract

The invention discloses a method and system for generating an electronic case history with informing and signing functions. The method comprises the following steps of: collecting a voice file and a medical image file during diagnosis of a doctor on a patient; transmitting the voice file and the medical image file to a server; resolving the received voice file by the server to obtain a voice resolving result, and resolving the received medical image file by the server to obtain a medical image resolving result; converting the voice resolving result and the medical image resolving result into text files; comparing the converted text files with pre-stored medical terms; performing medical term error correction to form an electronic case history file; storing the electronic case history file; configuring the corresponding relationship between the formed electronic case history and a client of the patient or a family member of the patient; marking the time of an event in the electronic case history to form a timestamp; sending an informing and signing notice to the client of the patient or the family member of the patient corresponding to the electronic case history file; receiving the informing and signing notice by the client of the patient or the family member of the patient; and storing notice receiving feedback information into the electronic case history file.

Description

technical field [0001] The invention relates to the technical field of electronic medical records, in particular to a method and system for generating an electronic medical record with a notice function. Background technique [0002] Medical records are the original records of patients in the whole process of diagnosis and treatment in the hospital. Electronic medical records not only refer to static medical record information, but also include related services provided. Electronic medical records are information about personal lifelong health status and health care behaviors managed electronically, involving all process information of collection, storage, transmission, processing and utilization of patient information. Electronic medical records are electronic patient records based on a specific system that provides users with access to complete and accurate data, alerts, reminders, and clinical decision support systems. [0003] In recent years, due to the wide applicati...

AI Technical Summary

Problems solved by technology

[0003] In recent years, due to the wide application of informatization, medical institutions, especially hospitals above the county level, have generally replaced the original handwritten medical records with electronic medical record systems. There may be typos in the course records, which are difficult to detect when entering, often causing a lot of ambiguity, and even causing medical disputes in serious cases, which has extremely adverse effects on hospitals and individuals. In a more serious situation, there is also a lack of communication between doctors and patients. , which will form a potential doctor-patient conflict

In addition, with the use of the electronic medical record system, it often occurs that various notices cannot be printed and signed in a timely manner. The invited person does not sign on the consultation record sheet, and the family members do not sign when the treatment is given up. Signature, etc., unable to monitor electronic medical records in real time and effectively

Images