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Electronic medical record structuralization method

An electronic medical record and structured technology, applied in the direction of patient-specific data, etc., can solve the problem of fixed and single form of electronic medical records, achieve good computer semantic characteristics, avoid irregular medical records, and reduce missed diagnoses

Inactive Publication Date: 2019-11-26
BEIJING INSTITUTE OF TECHNOLOGYGY
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  • Abstract
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  • Claims
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AI Technical Summary

Problems solved by technology

[0004] The purpose of the present invention is to solve the current situation that the form of electronic medical records is fixed and single in the medical field, provide a medical knowledge base and decision support that are convenient to store and call, and propose a method for structuring electronic medical records

Method used

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  • Electronic medical record structuralization method

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Embodiment Construction

[0024] The specific implementation manners of the present invention will be further described in detail below in conjunction with the accompanying drawings and embodiments. The following examples are used to illustrate the present invention, but are not intended to limit the scope of the present invention.

[0025] Such as figure 1 As shown, a method for structuring electronic medical records includes the following steps:

[0026] 1) Manage data element documents and build electronic medical record templates;

[0027] 2) According to the electronic medical record template described in step 1), the medical personnel enter the electronic medical record template data into the electronic medical record data;

[0028] 3) For the electronic medical record data described in step 2), several symptom and sign dictionaries in the form of fields are provided for users to select and operate;

[0029] 4) Intelligently infer the disease probability on the symptom and sign data of the cli...

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Abstract

The invention relates to an electronic medical record structuralization method which comprises the following steps: 1) performing data element document management, and constructing an electronic medical record template; 2) according to the electronic medical record template in the step 1), inputting electronic medical record template data into electronic medical record data by medical personnel; 3) for the electronic medical record data in the step 2), providing a plurality of symptom and sign dictionaries existing in a field form for a user to perform click operation; 4) carrying out intelligent reasoning on the symptom and sign data of the click operation in the step 3), and giving prompt for examination items, related diagnosis and treatment schemes and applicable drugs required in a standard diagnosis and treatment guide; 5) generating and displaying the final medical record. The electronic medical record structuring method with flexibility, practicability and expandability is provided, a perfect and authoritative knowledge base system can be provided for medical researchers, powerful support is provided for clinical decision, and the missed diagnosis rate and the misdiagnosisrate are reduced.

Description

technical field [0001] The invention relates to a method for structuring electronic medical records. Background technique [0002] Electronic medical records are information about personal health status and medical care behaviors managed electronically, involving the collection, storage, transmission, processing and utilization of patient information, etc., and can be used as the main information source in medical treatment to replace paper medical records, providing beyond Services for paper medical records for medical, legal and administrative needs. [0003] Traditional electronic medical records store medical record texts electronically. Except for changes in storage and writing methods, the medical records themselves have not undergone any changes. At present, domestic electronic medical record products can be divided into scientific research applications and clinical applications, both of which have contradictions between fixed and flexible requirements. [0004] The...

Claims

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Application Information

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Patent Type & Authority Applications(China)
IPC IPC(8): G16H10/60
CPCG16H10/60
Inventor 汤海京
Owner BEIJING INSTITUTE OF TECHNOLOGYGY
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