Medical record generation method, device, system and equipment and storage medium

Abstract

The embodiment of the invention provides a medical record generation method, device, system and equipment and a storage medium, and the method comprises the steps that a first terminal obtains a medical record template corresponding to the type of a disease suffered by a target user, receives answer information input for a template question in the medical record template, generates first data information containing the template question and the answer information, and sends the first data information to the target user; determining a medical description language corresponding to the first data information based on medical description languages corresponding to preset template questions and answer information, generating a first medical record file corresponding to the target user based on the corresponding medical description language, and sending the first medical record file to a second terminal, the second terminal is used for editing the first medical record file to generate a second medical record file corresponding to the target user. Visibly, according to the embodiment of the invention, based on structured storage of the data and the corresponding medical description language, the structured medical record file can be generated, and the quality and accuracy of the medical record file are improved.

Description

technical field [0001] The present disclosure relates to the technical field of medical big data and computer applications, and in particular, to a method, apparatus, system, device and storage medium for generating medical records. Background technique [0002] A medical record is a record of medical staff on the occurrence, development, outcome, examination, diagnosis, treatment and other medical activities of a patient's disease. Patient Medical Health File. Therefore, the recording of medical records is of great significance for medical treatment, teaching and clinical research. [0003] In the current related technologies, the generation method of electronic medical records usually involves medical staff manually converting paper medical records into electronic medical records. However, this electronic medical record generation method consumes a lot of working time of medical staff, and because different medical staff have Different writing habits may cause the proble...

AI Technical Summary

Problems solved by technology

[0003] In the current related technologies, the generation of electronic medical records usually involves medical staff manually converting paper medical records into electronic medical records. Different writing habits may cause the problem of low accuracy of the generated electronic medical records

[0004] With the rapid development of machine learning and artificial intelligence, the generation of electronic medical records usually includes the use of artificial intelligence to analyze and process the original medical records. Due to the need to use a large amount of data for machine learning to improve the accuracy of matching with professional description vocabulary, Therefore, it will affect the quality of structured medical records

[0005] It can be seen that the current medical record generation method may cause the problems of poor quality and low accuracy of the generated medical record files, and, due to the consumption of a large amount of working time of medical staff, there may be a problem of low efficiency of medical staff receiving consultations

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