Outpatient medical record quality control system and method

Abstract

The embodiment of the present invention discloses an outpatient medical record quality control system and method. The system includes: a medical record loading module, a medical record storage module and a medical record query module; the medical record loading module is configured to determine the target medical record from at least two pre-deployed candidate medical records and load the target medical record according to the medical record applicable attribute information obtained through the medical record setting window; the medical record storage module is configured to store the new version of the target medical record obtained after the medical record record is changed when the medical record included in the previous version of the target medical record is changed; the medical record query module is configured to obtain at least two versions of the target medical record when a trace query event of the target medical record is detected; and, according to the comparison results between the medical record records included in each version of the target medical record, the change traces of the target medical record are displayed. The application scheme can automatically match and load the target medical record with a suitable medical record structure according to the needs, and realize accurate tracing of medical record changes.

Description

Technical Field

[0001] The embodiments of the present invention relate to the field of medical technology, and in particular to an outpatient medical record quality control system and method. Background Art

[0002] With the rapid development of information technology, electronic medical records have been widely used in various hospitals. Electronic medical records can assist medical staff in writing and querying, improving work efficiency. However, with the continuous in-depth application of electronic medical records, some medical record quality issues have also been highlighted; for example, the structure of electronic medical records needs to be manually adjusted according to department needs and diagnosis needs, resulting in a chaotic medical record structure; and the inability to know the content changes in the electronic medical records has caused great difficulties in the medical record quality control process. Therefore, how to control the quality of electronic medical records becomes particularly important. Summary of the invention

[0003] The embodiment of the present invention provides an outpatient medical record quality control system and method to unify the electronic medical record structure according to diagnosis requirements and intuitively display the changed content of the electronic medical record.

[0004] In a first aspect, an embodiment of the present invention provides an outpatient medical record quality control system, comprising: a medical record loading module, a medical record storage module and a medical record query module; wherein:

[0005] The medical record loading module is configured to determine a target medical record from at least two pre-deployed candidate medical records according to the medical record applicable attribute information obtained through the medical record setting window, and load the target medical record;

[0006] The medical record storage module is configured to store a new version of the target medical record obtained after the medical record is changed when the medical record included in the previous version of the target medical record is changed;

[0007] The medical record query module is configured to, when a trace query event of the target medical record is detected, obtain at least two versions of the target medical record; and, based on the comparison results between the medical record records included in each version of the target medical record, display the traces of changes to the target medical record.

[0008] In a second aspect, an embodiment of the present invention further provides an outpatient medical record quality control method, comprising:

[0009] According to the medical record applicable attribute information obtained through the medical record setting window, determine a target medical record from at least two pre-deployed candidate medical records, and load the target medical record;

[0010] When the medical record included in the previous version of the target medical record is changed, the new version of the target medical record obtained after the medical record is changed is stored;

[0011] When a trace query event of the target medical record is detected, at least two versions of the target medical record are obtained; and based on the comparison results between the medical record records included in each version of the target medical record, the change traces of the target medical record are displayed.

[0012] An outpatient medical record quality control system is provided in an embodiment of the present invention. The system can obtain medical record applicable attribute information input by medical personnel through a medical record setting window, and determine a target medical record from at least two pre-deployed candidate medical records according to the input medical record applicable attribute information for loading. The system can automatically match and load a target medical record with a suitable medical record structure according to actual needs, so as to unify the medical record structure and avoid confusion in the medical record structure due to manual adjustment at a later stage. Moreover, when the medical record records included in the previous version of the target medical record are changed, the new version of the target medical record obtained after the medical record records are changed will be stored. Next, when a trace query event of the target medical record is detected, the change traces of the target medical record can be displayed according to the comparison results between the medical record records included in each version of the target medical record, so as to realize visual display of the medical record changes and thus realize accurate tracing of the medical record changes.

[0013] The above invention content is only an overview of the technical solution of the present invention. In order to more clearly understand the technical means of the present invention, it can be implemented according to the contents of the specification. In order to make the above and other purposes, features and advantages of the present invention more obvious and easy to understand, the specific implementation methods of the present invention are listed below. BRIEF DESCRIPTION OF THE DRAWINGS

[0014] Other features, objects and advantages of the present invention will become more apparent by reading the detailed description of non-limiting embodiments made with reference to the following drawings. The drawings are only for the purpose of illustrating preferred embodiments and are not to be considered as limiting the present invention. Also, the same reference symbols are used throughout the drawings to represent the same parts. In the drawings:

[0015] Figure 1 It is a structural block diagram of an outpatient medical record quality control system provided in an embodiment of the present invention;

[0016] Figure 2 It is a schematic diagram of the architecture of outpatient medical record quality control provided in an embodiment of the present invention;

[0017] Figure 3 It is a flow chart of an outpatient medical record quality control method provided in an embodiment of the present invention. DETAILED DESCRIPTION

[0018] The present invention will be further described in detail below in conjunction with the accompanying drawings and embodiments. It is to be understood that the specific embodiments described herein are only used to explain the present invention, rather than to limit the present invention. It should also be noted that, for ease of description, only the parts related to the present invention, rather than all structures, are shown in the accompanying drawings.

[0019] Before discussing the exemplary embodiments in more detail, it should be mentioned that some exemplary embodiments are described as processes or methods depicted as flow charts. Although the flow charts describe the operations (or steps) as sequential processes, many of the operations (or steps) therein can be implemented in parallel, concurrently or simultaneously. In addition, the order of the operations can be rearranged. The process can be terminated when its operation is completed, but can also have additional steps not included in the accompanying drawings. The process can correspond to a method, function, procedure, subroutine, subprogram, etc.

[0020] The outpatient medical record quality control system and method provided in the embodiments of the present invention are described in detail below through various embodiments and optional solutions of each embodiment.

[0021] Figure 1 is a structural block diagram of an outpatient medical record quality control system provided in an embodiment of the present invention. The technical solution of this embodiment can be applied to the situation of quality control of electronic medical records used in outpatient clinics. Figure 1 As shown, the outpatient medical record quality control system 100 in the embodiment of the present application may include: a medical record loading module 110, a medical record storage module 120 and a medical record query module 130. Among them:

[0022] The medical record loading module 110 is configured to determine a target medical record from at least two pre-deployed candidate medical records according to the medical record applicable attribute information obtained through the medical record setting window, and load the target medical record.

[0023] The medical record storage module 120 is configured to store a new version of the target medical record obtained after the medical record is changed when the medical record included in the previous version of the target medical record is changed.

[0024] The medical record query module 130 is configured to, when a trace query event of a target medical record is detected, obtain at least two versions of the target medical record; and display the traces of changes to the target medical record based on the comparison results between the medical record records included in each version of the target medical record.

[0025] In this embodiment, Figure 2 Schematic diagram of an outpatient medical record quality control system provided in an embodiment of the present invention. Figure 2, the quality control process of outpatient medical records can usually be divided into three stages: pre-quality control of electronic medical records, in-process quality control, and post-quality control. In the pre-quality control stage, the medical record setting window interface can be displayed, and medical staff can enter the medical record applicable attribute information such as the department, disease type, and gender applicable to the medical record on the medical record setting window interface. In this way, the medical record applicable attribute information entered by the medical staff can be obtained through the medical record setting window.

[0026] In this embodiment, the medical record structures adapted to different departments may be different, the medical record structures adapted to different diseases may be different, and the medical record structures adapted to different genders may also be different. Therefore, when loading medical records, it is necessary to first select the target medical record that meets the actual needs from at least two pre-deployed candidate medical records based on the medical record applicable attribute information entered by the medical staff. In this way, the obtained medical records do not need to be manually adjusted after loading, which can avoid confusion in the medical record structure and low medical record quality.

[0027] In an alternative solution of this embodiment, the embodiment of the present invention can be combined with each alternative solution in one or more of the above embodiments. Figure 1 and Figure 2 In the outpatient medical record quality control system 100 of the embodiment of the present application, the medical record loading module 110 is specifically configured as follows: based on the medical record applicable attribute information obtained through the medical record setting window, at least one target medical record whose medical record structure data matches the medical record structure data required by the medical record applicable attribute information is screened from at least two pre-deployed candidate medical records.

[0028] In this embodiment, the medical record applicable attribute information may include the following: the medical record applicable department, the medical record applicable disease type, and the medical record applicable gender. For the medical record applicable department, when loading the medical record, the candidate medical record template can be automatically filtered according to the input medical record applicable department, and the candidate medical record that is suitable for the current applicable department can be automatically identified as the target medical record. For the medical record applicable disease type, the relationship between the diagnosis and the disease type can be determined based on the current patient's diagnosis, and the candidate medical record that is suitable for the current applicable disease type can be automatically identified as the target medical record.

[0029] In this embodiment, for the applicable gender of medical records, special medical record structures and special medical record vocabulary for men and women can be pre-set. When loading medical records, the medical record structures that do not match the applicable gender of the medical records in the candidate medical records are automatically shielded, and the shielding does not affect the overall structure of the medical records. For example, the menstrual history is pre-set as female-only. When loading medical records, the medical records of male patients will automatically shield the menstrual history structure by judging the applicable gender of the medical records. In addition, cleft lip and palate are pre-set to be suitable for ages under 3 years old. When loading medical records, the current patient's age is judged to be greater than 3 years old, and medical records with cleft lip and palate are automatically filtered. It should be noted that for the schemes such as the applicable department of medical records, the applicable disease types of medical records, and the applicable gender of medical records, one or more medical record applicable attribute information can be used in combination.

[0030] In this embodiment, after the target medical record is determined, the determined target medical record can be loaded and displayed to the medical staff, so that the medical staff can input the medical record into the target medical record according to the diagnosis communication with the patient. Then, the target medical record with the input medical record can be submitted for storage.

[0031] In an alternative solution of this embodiment, the embodiment of the present invention can be combined with each alternative solution in one or more of the above embodiments. Figure 1 and Figure 2 In the outpatient medical record quality control system 100 of the embodiment of the present application, the medical record storage module 120 is also configured to store the medical record change time, medical record change operator and medical record change content included in the previous version of the target medical record when the medical record is changed.

[0032] In this embodiment, during the quality control stage, medical staff can change the medical records in the target medical records submitted for storage according to their needs. In order to achieve real-time tracing of medical record changes, the function of recording the change traces when the target medical records are changed can be displayed while providing the target medical records. When the medical records included in the previous version of the target medical records are changed, the new version of the target medical records obtained after the changed medical records are automatically stored, so as to know the medical record change process between the various versions according to the automatically stored versions of the target medical records. Among them, the medical record change includes at least one of the following operations: adding new medical records, deleting at least part of the original medical records, and modifying at least part of the original medical records.

[0033] In this embodiment, since a function is added to record the traces of medical record changes after the medical record is unarchived, when the medical record included in the previous version of the target medical record is changed, the target medical record for each medical record change will be retained. When querying the traces of the target medical record, different versions of the target medical record can be automatically captured from the database according to the medical record identifier of the target medical record, and the medical record records in the two versions of the target medical record can be compared to display the traces of changes in the target medical record at different times. In this way, the change process of the diagnosis and treatment medical record can be reproduced, which is convenient for quality control of the medical record.

[0034] In an alternative solution of this embodiment, the embodiment of the present invention can be combined with each alternative solution in one or more of the above embodiments. Figure 1 and Figure 2 In the outpatient medical record quality control system 100 of the embodiment of the present application, the medical record query module 130 is configured to: determine the case record comparison results between two adjacent versions according to the comparison results between the medical record records included in each version of the target medical record; and display the change traces between the two adjacent versions of the target medical record using a preset visual trace mark according to the case record comparison results between the two adjacent versions. Optionally, the change traces of different versions of medical records can be displayed using different colors or different lines.

[0035] In an alternative solution of this embodiment, the embodiment of the present invention can be combined with each alternative solution in one or more of the above embodiments. Figure 1 and Figure 2 In the outpatient medical record quality control system 100 of the embodiment of the present application, the outpatient medical record quality control system 100 of the present application also includes: a medical record verification module 140; the medical record verification module 130 is configured to verify missing items, illogical items, and inconsistent items in the target medical record when the target medical record is submitted.

[0036] In this embodiment, when the target medical record is submitted, it will automatically check whether there are missing items in the target medical record according to the mandatory items in the medical record writing specification. If it does not meet the requirements, the target medical record cannot be submitted and the printing of the target medical record is restricted. When the target medical record is submitted, the structured node symptom position in the target medical record is automatically determined. For example, the previous text is the left eye, and the latter text is the right eye. If the position is inconsistent and does not conform to logic, the medical record cannot be submitted and the printing of the medical record is restricted. When the target medical record is submitted, the logic of the context of the target medical record can be controlled and checked for the integrity of the content of the target medical record.

[0037] In an alternative solution of this embodiment, the embodiment of the present invention can be combined with each alternative solution in one or more of the above embodiments. Figure 1 and Figure 2In the outpatient medical record quality control system 100 of the embodiment of the present application, the department quality control personnel inspect and preliminarily score the medical records of the department. The outpatient medical record quality control system of the embodiment of the present application can summarize and query the department scoring results and automatically identify Class B and Class C medical records. In this way, the quality and efficiency of scientific research statistical query data of outpatient medical records can be improved, which is helpful for the research of special medical records.

[0038] In this embodiment, optionally, the department quality control personnel can score the outpatient medical records, and the medical record quality assessment is summarized in the statistical report: the outpatient medical record quality control system of the embodiment of the present application can count the medical record quality control results of the operating room or non-operating room by month, and the results are ranked by department. The scores of the grade A medical records, the number of grade B medical records, and the number of grade C medical records in the department are affected by the scoring results, and finally an average score is formed, and the departments are sorted by the average score. In this way, the work efficiency of the department quality control personnel can be improved, and the system automatically performs query statistics and score calculations, which greatly saves the time of quality control personnel and improves work efficiency.

[0039] An outpatient medical record quality control system is provided in an embodiment of the present invention. The system can determine a target medical record for loading from at least two pre-deployed candidate medical records according to input medical record applicable attribute information, and can automatically match and load a target medical record with a suitable medical record structure according to actual needs, thereby achieving a unified medical record structure, avoiding confusion in the medical record structure due to later manual adjustments, and improving the quality of outpatient medical record writing; and, when a trace query event of a target medical record is detected, the system can display the change traces of the target medical record based on the comparison results between the medical record records in each version of the target medical record, thereby achieving a visual display of the medical record changes, and further achieving accurate tracing of the medical record changes, and completely, truly and effectively recording the patient's medical information, so as to achieve information sharing and a basis for query.

[0040] Figure 3 1 is a flow chart of a method for quality control of outpatient medical records provided in an embodiment of the present invention. The technical solution of this embodiment can be applied to the situation of quality control of electronic medical records used in outpatient clinics. Figure 3 As shown, the outpatient medical record quality control method in the embodiment of the present application may include the following steps:

[0041] S310. Determine a target medical record from at least two pre-deployed candidate medical records based on the medical record applicable attribute information obtained through the medical record setting window, and load the target medical record.

[0042] Based on the above embodiment, optionally, the medical record applicable attribute information includes at least one of the following: the medical record applicable department, the medical record applicable disease type, and the medical record applicable gender;

[0043] According to the medical record applicable attribute information obtained through the medical record setting window, a target medical record is determined from at least two pre-deployed candidate medical records, including:

[0044] According to the medical record applicable attribute information obtained through the medical record setting window, at least one target medical record whose medical record structure data matches the medical record structure data required by the medical record applicable attribute information is screened from at least two pre-deployed candidate medical records.

[0045] S320. When the medical record included in the previous version of the target medical record is changed, a new version of the target medical record obtained after the medical record is changed is stored.

[0046] Based on the above embodiment, optionally, storing the new version of the target medical record obtained after changing the medical record includes:

[0047] The change time of the medical record, the operator of the medical record change, and the change content of the medical record when the previous version of the target medical record is changed are stored;

[0048] The medical record change includes at least one of the following operations: adding a new medical record, deleting at least part of the original medical record, and modifying at least part of the original medical record.

[0049] S330. When a trace query event of the target medical record is detected, at least two versions of the target medical record are obtained; and, based on the comparison results between the medical record records in each version of the target medical record, traces of changes to the target medical record are displayed.

[0050] Based on the above embodiment, optionally, according to the comparison results between the medical records in each version of the target medical record, the change traces of the target medical record are displayed, including:

[0051] According to the medical records included in each version of the target medical record, the case record comparison results between two adjacent versions are determined;

[0052] According to the comparison results of case records between two adjacent versions, a preset visual trace mark is used to display the change traces between the two adjacent versions of the target medical records.

[0053] On the basis of the above-mentioned embodiment, optionally, the outpatient medical record quality control method in the embodiment of the present application may also include the following operations: when submitting the target medical record, checking the missing items, illogical items and inconsistent items in the target medical record.

[0054] The outpatient medical record quality control method provided in the embodiment of the present invention can be executed by the outpatient medical record quality control system provided in any of the above-mentioned embodiments of the present invention, and the outpatient medical record quality control system has the corresponding functions and beneficial effects of executing the outpatient medical record quality control method. For technical details not described in detail in the above-mentioned embodiments, please refer to the operation process of the outpatient medical record quality control system provided in any embodiment of the present application.

[0055] In the description of this specification, the description with reference to the terms "one embodiment", "some embodiments", "examples", "specific examples", or "some examples" means that the specific features, structures, materials or characteristics described in conjunction with the embodiment or example are included in at least one embodiment or example of the present invention. In this specification, the schematic representation of the above terms does not necessarily refer to the same embodiment or example. Moreover, the specific features, structures, materials or characteristics described may be combined in any one or more embodiments or examples in a suitable manner.

[0056] Note that the above are only preferred embodiments of the present invention and the technical principles used. Those skilled in the art will understand that the present invention is not limited to the specific embodiments described herein, and that various obvious changes, readjustments and substitutions can be made by those skilled in the art without departing from the scope of protection of the present invention. Therefore, although the present invention has been described in more detail through the above embodiments, the present invention is not limited to the above embodiments, and may include more other equivalent embodiments without departing from the concept of the present invention, and the scope of the present invention is determined by the scope of the appended claims.

Claims

1. An outpatient medical record quality control system, characterized in that: include: Medical record loading module, medical record storage module and medical record query module; wherein: The medical record loading module is configured to determine a target medical record from at least two pre-deployed candidate medical records according to the medical record applicable attribute information obtained through the medical record setting window, and load the target medical record; The medical record storage module is configured to store a new version of the target medical record obtained after the medical record is changed when the medical record included in the previous version of the target medical record is changed; The medical record query module is configured to, when a trace query event of the target medical record is detected, obtain at least two versions of the target medical record; and display the change traces of the target medical record according to the comparison results between the medical record records included in each version of the target medical record; The medical record applicable attribute information includes at least one of the following: the medical record applicable department, the medical record applicable disease type, and the medical record applicable gender; The medical record loading module is further configured to: based on the medical record applicable attribute information obtained through the medical record setting window, screen at least one target medical record whose medical record structure data matches the medical record structure data required by the medical record applicable attribute information from at least two pre-deployed candidate medical records; Among them, the applicable department of the medical record is used to automatically filter the candidate medical record templates according to the input applicable department of the medical record, and automatically identify the candidate medical records that are suitable for the current applicable department as the target medical record; the applicable disease type of the medical record is used to judge the relationship between the diagnosis and the disease type according to the current patient's diagnosis, and automatically identify the candidate medical records that are suitable for the current applicable disease type as the target medical record; the applicable gender of the medical record is used to pre-set special medical record structures and special medical record vocabulary for men and women. When loading medical records, the medical record structures in the candidate medical records that do not match the applicable gender of the medical records are automatically shielded.

2. The system according to claim 1, characterized in that The medical record storage module is also configured as: The change time of the medical record, the operator of the medical record change, and the change content of the medical record when the previous version of the target medical record is changed are stored; The medical record change includes at least one of the following operations: adding a new medical record, deleting at least part of the original medical record, and modifying at least part of the original medical record.

3. The system according to claim 1, characterized in that The medical record query module is configured as follows: According to the medical records included in each version of the target medical record, the case record comparison results between two adjacent versions are determined; According to the comparison results of case records between two adjacent versions, preset visual trace marks are used to display the change traces between the two adjacent versions of the target medical records.

4. The system according to claim 1, characterized in that The system further comprises: a medical record checking module; the medical record checking module is configured to check missing items, illogical items and inconsistent items in the target medical record when the target medical record is submitted.

5. A method for quality control of outpatient medical records, characterized in that: The method comprises: According to the medical record applicable attribute information obtained through the medical record setting window, determine a target medical record from at least two pre-deployed candidate medical records, and load the target medical record; When the medical record included in the previous version of the target medical record is changed, the new version of the target medical record obtained after the medical record is changed is stored; When a trace query event of the target medical record is detected, at least two versions of the target medical record are obtained; and according to the comparison results between the medical record records included in each version of the target medical record, the trace of the change of the target medical record is displayed; The medical record applicable attribute information includes at least one of the following: the medical record applicable department, the medical record applicable disease type, and the medical record applicable gender; According to the medical record applicable attribute information obtained through the medical record setting window, a target medical record is determined from at least two pre-deployed candidate medical records, including: According to the medical record applicable attribute information obtained through the medical record setting window, at least one target medical record whose medical record structure data matches the medical record structure data required by the medical record applicable attribute information is selected from at least two pre-deployed candidate medical records; Among them, the applicable department of the medical record is used to automatically filter the candidate medical record templates according to the input applicable department of the medical record, and automatically identify the candidate medical records that are suitable for the current applicable department as the target medical record; the applicable disease type of the medical record is used to judge the relationship between the diagnosis and the disease type according to the current patient's diagnosis, and automatically identify the candidate medical records that are suitable for the current applicable disease type as the target medical record; the applicable gender of the medical record is used to pre-set special medical record structures and special medical record vocabulary for men and women. When loading medical records, the medical record structures in the candidate medical records that do not match the applicable gender of the medical records are automatically shielded.

6. The method according to claim 5, characterized in that The new version of the target medical record obtained after the medical record is changed is stored, including: The change time of the medical record, the operator of the medical record change, and the change content of the medical record when the previous version of the target medical record is changed are stored; The medical record change includes at least one of the following operations: adding a new medical record, deleting at least part of the original medical record, and modifying at least part of the original medical record.

7. The method according to claim 5, characterized in that According to the comparison results between the medical records in each version of the target medical record, the change traces of the target medical record are displayed, including: According to the medical records included in each version of the target medical record, the case record comparison results between two adjacent versions are determined; According to the comparison results of case records between two adjacent versions, preset visual trace marks are used to display the change traces between the two adjacent versions of the target medical records.

8. The method according to claim 5, characterized in that The method further comprises: When submitting the target medical records, check for missing items, illogical items, and inconsistent items in the target medical records.

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