Electronic medical record diagnosis and treatment quality control method based on clinical diagnosis and treatment guide

Abstract

The invention discloses a clinical diagnosis and treatment guide-based electronic medical record diagnosis and treatment quality control method. The method comprises the following steps: S1, establishing a guide-based quality control rule base; s2, carrying out data processing and standardized mapping on the electronic medical record and the inspection information; and S3, performing quality control judgment on the medical record text by utilizing a guide-based quality control rule base. The electronic medical record diagnosis and treatment quality control is carried out by utilizing the guide, the defect that the final medical record quality control is limited to form and lags behind the medical process is overcome, the standardized guide treatment specification can be utilized to help doctors to improve the diagnosis and treatment level and reduce misdiagnosis and treatment, homogeneous diagnosis and treatment of doctors of different levels are realized, the diagnosis and treatment deviation of the doctors is reduced, and the diagnosis and treatment efficiency is improved. The pressure of quality control personnel is reduced, and the method has very important significance for reducing medical risks.

Description

technical field [0001] The invention belongs to the technical field of medical system informatization, and in particular relates to a method for quality control of electronic medical record diagnosis and treatment based on clinical diagnosis and treatment guidelines. Background technique [0002] Medical records are the sum of words, symbols and other materials formed by medical personnel in the diagnosis and treatment work. They are the records of a series of medical behaviors such as the evolution of the patient's condition, the process of diagnosis and treatment, and the effect of medical workers. They are an important basis for medical insurance compensation and the key to hospital assessment. Indicators and strong evidence of medical disputes. It requires objectivity, completeness, and accuracy. [0003] Due to the gap in the diagnosis and treatment level of doctors with different seniorities, irregular diagnosis and treatment often occur in the process of diagnosis an...

AI Technical Summary

Problems solved by technology

[0003]Due to the gaps in the diagnosis and treatment level of doctors with different seniorities, irregular diagnosis and treatment often occur in the diagnosis and treatment process

First of all, the quality control of medical records at this stage depends on the final quality control. The amount of medical record data is large, the quality control practitioners are few, and the level is uneven.

Secondly, in real-time diagnosis and treatment, the electronic medical record system generally only conducts formal quality control, and cannot carry out connotative diagnosis and treatment quality control on unstructured data such as medical record documents and examinations.

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