System and method of self-help inquiry and generation of structured action case history

Abstract

The present invention discloses a system and method of self-help inquiry and generation of a structured action case history. A semanteme search module is configured to perform interpretation, list possible symptoms related to the symptom key words inputted by users for users to select the most closed symptom to obtain an action code; a merging symptom pairing module is configured to find out corresponding disease codes with respect to the action code in a disease symptom comparison table, and list all the symptom codes covered with the disease codes, wherein the symptom codes may be the merging symptom; a sequencing screening module is configured to screen and sequence the symptom codes of the user from the merging symptom, and display the symptoms of the symptom codes on a computer for users to check and then generate associated symptom codes, namely secondary action codes; the action codes and the associated symptom codes are arranged in turn to generate a group of template questionnaires, the content of the questionnaires are regulated with the users' answer results, and all the answer results structuredly generate a group of symptom combination case history codes.

Description

technical field [0001] The invention relates to a technology for generating medical records in a medical system, in particular to a system and method for self-service consultation and generating structured chief complaint medical records. Background technique [0002] In various fields of medicine, the content of clinical diagnosis includes: medical history inquiry (current medical history and past medical history), physical examination (physical examination), laboratory examination and imaging diagnostics, etc. Among them, whether doctors can establish good interaction with patients Communication and careful history taking are the first steps in diagnosis and treatment. Traditionally, doctors will listen to the patient's complaints first, then ask the patient some related questions, sort out clues from some symptoms or signs of the disease process, and put forward a diagnostic hypothesis from these clues, and then pass an objective physical examination , laboratory tests o...

AI Technical Summary

Problems solved by technology

[0003] In the current medical practice, the data presented subjectively by the patient needs to be recorded by the doctor. This is the medical record. However, in the busy clinic environment, there are many difficulties in the accuracy, completeness and economy of asking the medical history.

According to research statistics, doctors at the grassroots level can only implement 59% of the medical history data collected by asking patients, and 41% of the questions fail to ask patients, and doctors spend 20% of their time in outpatient practice Consumed in the production of medical records, so diagnosis and treatment records are very important in clinical work, high cost, but difficult to be effective, complete or accurate

If the complete medical record mechanism cannot be improved, it will be impossible to provide communication between the doctor and the patient and clarify the evolution of the disease and the complexity of the health status, and there will be hidden misunderstandings in the medical care of critically ill patients between different specialties, resulting in duplication of treatment or conflicts situation, reducing the quality of care

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