Structured report making and writing method

A technology for structured reporting and reporting, applied in the field of medical technology systems, can solve problems such as insufficient scalability, difficult coding of internal entries, and unfavorable old report information.

Pending Publication Date: 2020-10-27
宁波市科技园区明天医网科技有限公司
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  • Summary
  • Abstract
  • Description
  • Claims
  • Application Information

AI Technical Summary

Problems solved by technology

Unable to effectively extract the content of the imaging manifestations of the disease
[0004] 2. Insufficient scalability of reports
[0005] 3. The simple use of key-value pairs in structured entries cannot reflect the hierarchical structure relationship, resulting in unclear semantics
[0006] 4. Entry encoding operation is cumbersome and difficult to maintain
At present, there is no uniform code for most diseases, which need to be created by doctors themselves or modified later. It is very difficult to modify the codes of internal entries after most reports are produced, and it is difficult for doctors to operate, requiring the help of engineers, which is inefficient and unnecessary. Facilitate information extraction from old reports

Method used

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  • Structured report making and writing method

Examples

Experimental program
Comparison scheme
Effect test

Embodiment 1

[0044] The structured report preparation method described in this embodiment, such as figure 1 As shown, it includes the following steps:

[0045] (a) thesaurus construction, described thesaurus construction comprises:

[0046](a.1) Create a new Excel spreadsheet file. In the spreadsheet, first divide each column into different fields, wherein the first column is the code field, the second column is the structure name field, the third column is the functional classification field, and the first column is the field of the structure name. The fourth column is the first-level menu field, the fifth column is the second-level menu field, and so on; fill in the code of each entry in each row of the code field, and fill in the structure name field to indicate that the structure corresponding to the inspection structure in the report Fill in the entry of the functional classification in the functional classification field, and fill in the preset standard description entries for the i...

Embodiment 2

[0066] The structured report preparation method described in this embodiment, such as Figure 4 As shown, in addition to the features described in Embodiment 1, in order to speed up work efficiency, the step (d) also includes a step that can be executed in parallel with the step (d.1): (d.2) can save the report of the current patient at the same time As a disease template, when a patient of the same type is encountered, the disease template is invoked to generate a new report draft that can reduce editing time.

[0067] The method for making and writing a structured report provided in this embodiment can facilitate the writing of reports by patients of the same type through step (d.2) in actual operation. At the same time, after performing the saving in step (d), loading entries can realize no-delay loading except for the first time.

Embodiment 3

[0069] In addition to the features described in Embodiment 2, the structured report preparation method described in this embodiment is as follows: Figure 5 As shown, in order to make the sentence natural and convenient for editing and selection, the entries of the menus at all levels include underlined entries. If there is a sub-level menu after the menu with underlined entries, then by selecting The report editing program will replace the selected entry in the lower menu to the underlined position of the upper menu to form a complete sentence, and write the sentence into the patient report; if the menu with the underlined entry If it is the last level menu, after selecting the underlined entry, in the text input box, fill in freely editable text in the underlined position of the corresponding entry to replace the underline, for example, select " Apical wall thickening, _cm" menu entry, input the measurement result as 1.2 in the text input box, and the text "Apical wall thick...

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Abstract

The invention discloses a structured report making and writing method, which comprises the following steps of: (a) constructing a word bank, (b) translating an Excel spreadsheet word bank into a tree-shaped structure file through a code making tool; (c) loading the coded file of the structured template by using a report editing program and writing a report; and (d) after the entry selection is completed, storing the generated report, and meanwhile, storing the selected structured entry file. The invention discloses a structured report making and writing method. By means of the Excel file withthe specific structural content, a doctor can conveniently compile structural data and the hierarchical structure relation between the data, the Excel file is analyzed into a tree-shaped structural template, and rapid and accurate structural report writing is completed through mouse clicking and partial free editing of the content.

Description

technical field [0001] The invention relates to a medical technology system, in particular to a method for making and writing a structured report. Background technique [0002] Compared with traditional reports, structured reports are structured and regulated in content. Traditional reports are mostly written by doctors in natural language according to their own habits. The content logic is complex and the words are diverse. It is difficult to effectively extract the value information in the report. Incapable of information management and utilization. It not only wastes a lot of valuable medical record information, but also easily leads to omissions and mistakes in report writing. When the era of big data and artificial intelligence comes, structured medical record information is the most basic data. Therefore, the popularization and application of structured reports is imminent. The existing structured reports mainly have the following disadvantages: [0003] 1. The rep...

Claims

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Application Information

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IPC IPC(8): G16H15/00G06F40/18G06F40/14G06F40/154
CPCG16H15/00G06F40/18G06F40/14G06F40/154
Inventor 陆洋简刚唐武斌
Owner 宁波市科技园区明天医网科技有限公司
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