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Electronic medical record information correction method and system

An information correction, electronic medical record technology, applied in the field of information processing, can solve the problems of improving the quality of medical records and diagnosis and treatment process, unable to help doctors, and improving the efficiency of writing medical records, so as to avoid medical accidents, improve efficiency, and improve quality.

Active Publication Date: 2020-02-21
SHAN DONG MSUN HEALTH TECH GRP CO LTD
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  • Summary
  • Abstract
  • Description
  • Claims
  • Application Information

AI Technical Summary

Problems solved by technology

Such a medical record management system cannot help doctors improve the efficiency of writing medical records, nor can it review the content recorded in medical records to improve the quality of medical records and diagnosis and treatment processes
[0005] It can be seen that the technical problems existing in the current electronic medical records are: no use of the patient's previous medical record information, the latest inspection and test, and doctor's order content to assist the input of this medical record information, and no comprehensive use of various inspection and test results, doctor's order content and medical knowledge Checking the content of medical records cannot meet the existing needs in terms of standardization and accuracy of information

Method used

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  • Electronic medical record information correction method and system
  • Electronic medical record information correction method and system
  • Electronic medical record information correction method and system

Examples

Experimental program
Comparison scheme
Effect test

Embodiment 1

[0048] This embodiment discloses a method for correcting electronic medical record information, which obtains the required data from the hospital's HIS, LIS, PACS, and EMR systems (the four systems correspond to doctor's order, inspection, inspection, and medical record information respectively), and on server A After processing, the result is sent to the client where the doctor writes the medical record.

[0049] The medical record includes the following three parts: admission record, course record, and discharge record. The course record is divided into three types, namely, the first course record, the course record of the first ward round, and the follow-up course record.

[0050] See attached figure 1 As shown, step (1): establish a medical knowledge map, the knowledge map includes symptoms->diagnosis, signs->diagnosis, test results->diagnosis, test results->diagnosis, diagnosis->medicine, diagnosis->medical operations (including inspection, testing, surgery, etc.), the k...

Embodiment 2

[0111] An electronic medical record information correction system, including a server, the server is configured to:

[0112] Establish a medical knowledge graph;

[0113] Receive the admission record information of newly admitted patients, and receive the admission record information of this patient based on the admission record and discharge record information of the patient's previous admission for patients who are re-admitted due to the same disease, and assist in writing the patient's admission record;

[0114] Receive the first course record information based on the patient's admission record, latest inspection results, and doctor's order information, and assist in completing the first course record;

[0115] Receive the first ward round medical course record information based on the first medical course record, the latest inspection results, and doctor's order information, and assist in completing the first ward round medical course record;

[0116] Receive the follow-u...

Embodiment 3

[0122] A computer device, comprising a memory, a processor, and a computer program stored on the memory and operable on the processor, wherein the processor implements the following steps when executing the program:

[0123] Establish a medical knowledge graph;

[0124] Receive the admission record information of newly admitted patients, and receive the admission record information of this patient based on the admission record and discharge record information of the patient's previous admission for patients who are re-admitted due to the same disease, and assist in writing the patient's admission record;

[0125] Receive the first course record information based on the patient's admission record, latest inspection results, and doctor's order information, and assist in completing the first course record;

[0126] Receive the first ward round medical course record information based on the first medical course record, the latest inspection results, and doctor's order information,...

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Abstract

The invention discloses an electronic medical record information correction method and system. The method comprises the steps of establishing a medical knowledge graph; receiving first disease courserecord information input based on the admission record, the latest examination result and doctor's advice information of a patient; receiving first ward round disease course record information input based on the first disease course record, the latest examination result and the doctor's advice information; receiving subsequent disease course record information input based on the previous two disease course records, the latest examination result and the doctor's advice information of the patient; receiving and displaying discharge record information input based on the admission record, all disease course records, the latest examination result and doctor's advice of the patient. In the process, the admission record information, the first disease course record information, the first ward round disease course record information, the subsequent disease course record information and the discharge record information of the secondary patient are subjected to information correction by using themedical knowledge graph, and the correction result is displayed, so that the efficiency of writing medical records by doctors is effectively improved.

Description

technical field [0001] The invention belongs to the field of information processing, in particular to an electronic medical record information correction method and system. Background technique [0002] The statements in this section merely provide background information related to the present disclosure and do not necessarily constitute prior art. [0003] It is an important task for doctors in clinical work to record in detail the patient's disease progression and diagnosis and treatment process in the medical record. However, in actual work, due to the large number of patients and the complexity of the situation, the work of writing medical records takes a lot of time for doctors, and doctors do not have enough time to record patients' conditions in detail, which has caused many missing in electronic medical records. Necessary medical information, the contents of the medical records do not conform to the relevant norms of the medical profession; have a large negative im...

Claims

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Application Information

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IPC IPC(8): G16H10/60G16H15/00G16H50/20
CPCG16H10/60G16H15/00G16H50/20
Inventor 孙钊吴军高希余樊昭磊刘小梅张之林丁磊
Owner SHAN DONG MSUN HEALTH TECH GRP CO LTD
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