Electronic medical record and medical record home page diagnosis consistency verification method and system

Abstract

The invention discloses an electronic medical record and medical record home page diagnosis consistency verification method and system. The method comprises the steps: acquiring one or more diagnosisnames in medical record home page information; determining whether the diagnosis name meets a preset accepting and excluding condition of a pre-constructed international disease classification ICD10 coding characteristic knowledge base or not; grouping the diagnosis names according to the core diseases in response to the fact that the diagnosis names meet the accepting and excluding conditions; obtaining a first feature set of a core disease corresponding to each group of diagnosis from the ICD10 coding feature knowledge base; structuring the electronic medical record information according tothe structure of the ICD10 coding feature knowledge base; obtaining a second feature set of the core disease corresponding to each group of diagnosis from the structured electronic medical record information; sequentially comparing the acquired first feature set with the acquired second feature set according to the core disease; and outputting a verification result of whether the electronic medical record and the medical record home page diagnosis are consistent or not according to the comparison result. According to the invention, the consistency between the electronic medical record and themedical record home page diagnosis can be accurately verified.

Description

technical field [0001] This application relates to the field of electronic digital data processing, in particular to a method and system for verifying the consistency of diagnosis on the first page of electronic medical records and medical records. Background technique [0002] The International Classification of Diseases (ICD) is an international unified classification of various diseases issued by the World Health Organization (WHO) in order to enable health practitioners to exchange health information around the world. Diseases are classified into categories according to the rules and expressed by codes, which contain tens of thousands of unique codes related to injuries, diseases and causes of death. The most widely used ICD versions in the world are ICD10 and ICD9. [0003] ICD enables the standardization and formatting of disease terminology, which is the application basis of medical informatization and medical information management, and also an important basis for m...

AI Technical Summary

Problems solved by technology

By mapping medical terms or original diagnosis names to ICD10 codes, it can verify the consistency of the diagnosis on the homepage and the diagnosis in the clinical documents to a certain extent, and check for deficiencies in the diagnosis on the homepage, but it cannot handle medical terms outside the dictionary , the scalability is low, and it cannot solve the problem of differences between diagnosis writing and home page diagnosis in real clinical documents

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