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Electronic medical record writing quality inspection system and method

A technology of electronic medical records and inspection systems, applied in the fields of healthcare informatics, healthcare resources or facilities, instruments, etc., can solve the problems of difficult traceability, difficult medical record management and control, etc., to promote management, improve the level of information management, and facilitate the The effect of the query

Pending Publication Date: 2021-05-11
上海市嘉定区南翔医院
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Problems solved by technology

However, the existing technology can no longer meet the requirements of refined management of electronic medical record writing quality by relying on manual work alone.
Due to the large number of medical record quality control control nodes, it is difficult to control every department, every doctor and every medical record in the existing technology, and it is even more difficult to realize the traceability of the whole process

Method used

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  • Electronic medical record writing quality inspection system and method
  • Electronic medical record writing quality inspection system and method
  • Electronic medical record writing quality inspection system and method

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Embodiment Construction

[0020] In order to make the object, technical solution and advantages of the present invention clearer, the present invention will be further described in detail below in conjunction with the accompanying drawings and embodiments. It should be understood that the specific embodiments described here are only used to explain the present invention, not to limit the present invention.

[0021] While the following description sets forth various implementations that may, for example, be shown in a system architecture, implementations of the techniques and / or arrangements described herein are not limited to a particular system architecture and / or computing system, and may be implemented with any An architecture and / or computing system is implemented. For example, techniques and / or arrangements described herein may be implemented using various architectures, such as one or more integrated circuit chips and / or packages, and / or various computing devices and / or electronic devices. Furth...

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Abstract

The invention provides an electronic medical record writing quality inspection system and method. The checking system comprises an automatic checking module for automatically checking the writing quality of the electronic medical record according to the electronic medical record quality assessment index, and a manual auxiliary checking module for carrying out manual auxiliary checking on the writing quality of the electronic medical record according to the electronic medical record quality assessment index. The automatic troubleshooting module and / or the manual auxiliary troubleshooting module can comprise a summary query module which is used for performing summary query on medical records in a summary query time period so as to obtain department completion conditions and / or physician personal completion conditions; the department inquiry module is used for carrying out department inquiry on department medical records in a department inquiry time period according to the related information of the medical records so as to obtain the personal completion condition of the physician and / or inquiring the medical records which are not completed by the physician or do not reach the standard.

Description

technical field [0001] The invention relates to the field of intelligent management and control of electronic medical records, in particular to a system and method for checking the writing quality of electronic medical records. Background technique [0002] According to the existing medical record quality control standards, medical record writing basic norms and medical record writing quality assessment indicators and other diagnosis and treatment norms and medical record quality control requirements, it is required to strengthen the control of the connotative quality of medical records. However, the existing technology can no longer meet the requirements of fine management of electronic medical record writing quality only by manual work. Due to the large number of control nodes for medical record quality control, it is difficult to control every department, every doctor and every medical record in the existing technology, and it is even more difficult to realize the traceab...

Claims

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Application Information

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IPC IPC(8): G16H10/60G16H15/00G16H40/20
CPCG16H10/60G16H15/00G16H40/20
Inventor 周海龙封卫征张华鹤厉海洋吴强钱丽静朱晓玲金莉莎周艳丽张晓影
Owner 上海市嘉定区南翔医院
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