Medical record writing quality control method and system

A quality control method and medical record technology, applied in the field of medical record management, can solve the problems of medical record quality control lag, poor quality, and failure to remind in time, and achieve the effect of good real-time performance and high writing quality

Pending Publication Date: 2020-11-20
WINNING HEALTH TECHNOLOGY GROUP CO LTD
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  • Summary
  • Abstract
  • Description
  • Claims
  • Application Information

AI Technical Summary

Problems solved by technology

[0003] In order to solve the technical problems that the existing medical record quality control lags behind, the quality is poor, and cannot be reminded in time, the present invention provides a quality control method and a quality control system for medical record writing

Method used

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  • Medical record writing quality control method and system
  • Medical record writing quality control method and system

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Experimental program
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Effect test

Embodiment 1

[0043] See figure 1 as well as figure 2 This embodiment provides a quality control method for medical record writing. The quality control method is used for quality control of medical records written by doctors. It mainly includes two closed-loop quality control processes, one of which is automated closed-loop quality control for doctors based on NLP technology, and the other One is based on NLP technology to automate QC closed-loop quality control. The quality control method of this embodiment can be implanted in the electronic medical record system in the form of a quality control AI assistant, and combined with the standard data set of the medical record, data elements, range dictionary, quality control rule library and other knowledge base data, it can provide the basic health service center, Quality control and management of medical records generated in hospitals and other medical places. Among them, the quality control method includes the following steps.

[0044] When t...

Embodiment 2

[0063] This embodiment provides a method for quality control of medical record writing, which defines the content of the time limit rule on the basis of Embodiment 1. Among them, the time limit rule one includes that the medical record needs to complete the first course of the disease within a preset time of admission (for example: the first course of illness is completed within 8 hours of admission), and the writing time of the medical record must be less than a preset time of 2. The first time limit rule can ensure the efficiency of writing medical records. Both the preset time one and the preset time two can be determined according to different departments, different doctors and different diseases. The second time limit rule includes that the first processing time of the medical record needs to be less than a preset time 3, the medical record modification time needs to be less than a preset time 4, and the medical record completion time needs to be less than a preset time 5. ...

Embodiment 3

[0065] This embodiment provides a method for quality control of medical record writing, which limits data integrity on the basis of Embodiment 1. Among them, the data integrity rule 1 or the data integrity rule 2 includes whether the diagnosis data in the medical record must be missing, the examination data in the medical record must be missing, and the examination items in the medical record must meet the check items related to the patient's condition description , The medical record should indicate the number and amount of use of the drugs prescribed by the doctor each day, and the medical record should indicate the patient’s review time and review information. In this embodiment, the first data integrity rule or the second data integrity rule are the same. Checking the integrity of these data can improve the writing quality of medical records, so that patients can view the information they need in time based on the medical records, thereby improving the quality of medical se...

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Abstract

The invention discloses a medical record writing quality control method and system. The quality control method comprises the following steps: matching a corresponding quality control rule I accordingto the treatment diagnosis of a patient, the disease description of the patient, vital signs and an examination result, and reminding a doctor in real time when a written medical record does not conform to the quality control rule I; submitting medical records; judging whether the medical record meets a time limit rule I, a data integrity rule I, a data consistency rule I and a medical record scoring rule I or not; if so, printing the medical record, otherwise, displaying the problem to a doctor; inquiring the medical record of the patient, automatically matching a quality control rule II andopening the medical record; judging whether the medical record meets a second time limit rule, a second data integrity rule, a second data consistency rule and a second medical record scoring rule ornot; if yes, displaying a question-free record, and otherwise, displaying a defect question and returning the defect question to the doctor, wherein the doctor modifies the medical record and answersthe question. The writing quality of medical records is improved, the real-time performance is good, meanwhile, the medical burden is relieved, and the medical record management difficulty is reduced.

Description

Technical field [0001] The invention relates to a quality control method in the technical field of medical record management, in particular to a quality control method for medical record writing, and also to a medical record writing quality control system. Background technique [0002] In the process of writing medical records, doctors mostly rely on the doctor's past experience and professionalism for the accuracy and standardization of medical records, and the quality of medical records is difficult to guarantee. In the subsequent random check of medical records, problems with medical records were found, but most of them were quality control after the fact, so the quality control lags behind. In addition, in the process of medical record management, there is no real-time reminder when doctors write medical records, and differentiated reminders based on different departments and different diagnoses. Summary of the invention [0003] In order to solve the existing technical probl...

Claims

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Application Information

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Patent Type & Authority Applications(China)
IPC IPC(8): G06F40/205G06F40/166G16H10/60G16H80/00
CPCG06F40/205G06F40/166G16H10/60G16H80/00
Inventor 王玉贞王国伟王涛吴玲玉赵大平黄克华王晓鹏黄智勇陈旭
Owner WINNING HEALTH TECHNOLOGY GROUP CO LTD
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