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

Abstract

The invention discloses a medical record generation method and device, electronic equipment and a storage medium, the method and device are applied to the electronic equipment, and time point records based on a time sequence are obtained through disassembly and structural processing of medical original data obtained through multiple ways. The time point record comprises classification standardization data based on an initial necessary rule; generating and displaying customized template information based on the time point record; and generating a medical record based on the customized template information, wherein the medical record comprises a formal medical record. According to the scheme, the underlying data of the medical records are arranged and evolved more orderly and called and applied in the form of the customized template, so that a user can operate the data and the template according to actual conditions, the processing efficiency of the medical records can be greatly improved, various different requirements are met, and the user experience is improved. All applications constructed on the medical data structure are upgraded essentially, including but not limited to generation of more accurate high-quality electronic medical records, data management operation according to user requirements, generation of customized medical scientific research records, generation of customized medical data analysis and reports, AI training in the medical field and the like.

Description

Technical Field

[0001] The present application relates to the technical field of medical equipment, and more specifically, to a method, device, electronic device and storage medium for generating medical records. Background Art

[0002] With the advancement and popularization of hospital informatization, medical institutions will generate a series of medical records in the course of their work, including disease information, laboratory information, treatment information, life information, etc. during each visit, treatment, scientific research or visit. In the field of informatization, these medical records will form a huge and complex medical information data pile based on the time axis. Since the information carried in medical records currently lacks a relatively unified and standard format, it is difficult for doctors, medical institutions and other related institutions to efficiently process and use the huge amount of health data that has been deposited in medical records, which in turn makes it difficult for medical practitioners to fully enjoy the work efficiency improvement brought by the informatization of the core medical field, and hinders the in-depth promotion of informatization application technologies in the medical industry, such as data interconnection, big data description, and simulation research and development of new drugs. Summary of the invention

[0003] In view of this, the present application provides a method, device, electronic device and storage medium for generating medical records, which are used to standardize data in the core medical field, thereby improving the efficiency of information retrieval and operation, and essentially upgrading all applications built on this medical data structure, including but not limited to generating more accurate high-quality electronic medical records, performing data management operations according to user needs, generating customized medical research records, generating customized medical data analysis and reports, AI training in the medical field, etc., thereby facilitating medical practitioners to efficiently record, operate and use medical records.

[0004] In order to achieve the above objectives, the proposed solution is as follows:

[0005] A method for generating medical records, applied to an electronic device, comprising the steps of:

[0006] By disassembling and structuring the original medical data obtained from multiple channels, a time point record based on time sequence is obtained, and the time point record includes classified and standardized data based on the initial necessary rules;

[0007] Based on the data call and operation request input by the user through the display interface, generate and display customized template information based on the time point record;

[0008] Based on a record generation request from a user, a medical record is generated based on the customized template information, wherein the medical record includes a formal medical record.

[0009] Optionally, the time point record includes an initial time point record, a subsequent time point record and a final time point record which are formed based on a preset initial rule and have a data association relationship.

[0010] Optionally, the display interface includes a record view interface and a time point view interface.

[0011] Optionally, the generating and displaying customized template information comprises the steps of:

[0012] Generate and display the customized template information based on a preset output mode;

[0013] The customized template information is added, modified or deleted based on the modification rules and the modification request input by the user through the display interface.

[0014] Optionally, the user-based record generation request generates a medical record based on the customized template information and the time point record, wherein the medical record includes a formal medical record, including the steps of:

[0015] Receiving the record generation request using an integrated operating platform;

[0016] The integrated operating platform is used to generate a text document based on the customized template and the time point record, and the text document is used for the user to call and generate the formal medical record.

[0017] Optionally, the following steps are also included:

[0018] The record output rules are selected according to the user's needs, and the initial medical record, follow-up medical record, medical course record or major medical record are generated and output based on the time point records.

[0019] A medical record generation device, applied to an electronic device, comprising:

[0020] A time point record module is configured to obtain time point records based on time sequence by disassembling and structuring the original medical data obtained from multiple channels, wherein the time point records include classified and standardized data based on initial rules;

[0021] A first generating module is configured to generate and display customized template information based on the time point record based on the data call and operation request input by the user through the display interface;

[0022] The second generating module is configured to generate a medical record based on the user's record generation request and based on the customized template information, wherein the medical record includes a formal medical record.

[0023] Optionally, also include:

[0024] The record output module is configured to select record output rules according to user needs, and generate and output initial medical records, follow-up medical records, medical history records or major medical records based on the time point records.

[0025] An electronic device comprises at least one processor and a memory connected to the processor, wherein:

[0026] The memory is used to store computer programs or instructions;

[0027] The processor is used to execute the computer program or instruction so that the electronic device implements the method for generating medical records as described above.

[0028] A storage medium is applied to an electronic device, wherein the storage medium carries one or more computer programs, and the one or more computer programs can be executed by the electronic device, so that the electronic device implements the medical record generation method as described above.

[0029] As can be seen from the above technical scheme, the present application discloses a method, device, electronic device and storage medium for generating medical records. The method and device are applied to electronic devices, and the time point record based on the time sequence is obtained by disassembling and structuring the original medical data obtained from multiple channels. The time point record includes the classified standardized data based on the initial necessary rules; the customized template information is generated and displayed based on the time point record; the medical record is generated based on the customized template information, and the medical record includes the formal medical record. Through the above scheme, the underlying data of the medical record is arranged and evolved in a more orderly manner, and is called and applied in the form of a customized template, so that the user can operate the data and template according to the actual situation, so that the processing efficiency of the medical record can be greatly improved, meet a variety of different needs, and essentially upgrade all applications built on this medical data structure, including but not limited to generating more accurate high-quality electronic medical records, performing data management operations according to user needs, generating customized medical research records, generating customized medical data analysis and reports, AI training in the medical field, etc. BRIEF DESCRIPTION OF THE DRAWINGS

[0030] In order to more clearly illustrate the embodiments of the present application or the technical solutions in the prior art, the drawings required for use in the embodiments or the description of the prior art will be briefly introduced below. Obviously, the drawings described below are only some embodiments of the present application. For ordinary technicians in this field, other drawings can be obtained based on these drawings without paying creative work.

[0031] Figure 1 A flowchart of a method for generating a medical record according to an embodiment of the present application;

[0032] Figure 2 A schematic diagram of a data collection path for medical records during remote consultation in an embodiment of the present application;

[0033] Figure 3 A schematic diagram of the data format path of the medical condition record when adding data in the embodiment of the present application;

[0034] Figure 4 A schematic diagram of a generation node of a medical record according to an embodiment of the present application;

[0035] Figure 5 A flowchart of another method for generating medical records according to an embodiment of the present application;

[0036] Figure 6 A block diagram of a medical record generation device according to an embodiment of the present application;

[0037] Figure 7 A block diagram of another medical record generation device according to an embodiment of the present application;

[0038] Figure 8 A block diagram of an electronic device according to an embodiment of the present application. DETAILED DESCRIPTION

[0039] The following will be combined with the drawings in the embodiments of the present application to clearly and completely describe the technical solutions in the embodiments of the present application. Obviously, the described embodiments are only part of the embodiments of the present application, not all of the embodiments. Based on the embodiments in the present application, all other embodiments obtained by ordinary technicians in this field without creative work are within the scope of protection of this application.

[0040] Figure 1 The present invention is a flowchart of a method for generating medical records according to an embodiment of the present application.

[0041] like Figure 1 As shown, the generation method provided in this embodiment is applied to an electronic device, and is used to generate corresponding medical records based on raw medical data. The electronic device can be understood as a computer, server, cloud platform, etc. with data computing and information processing capabilities. The generation method specifically includes the following steps:

[0042] S1. Obtain time point records based on time sequence according to the original medical data.

[0043] By disassembling and structuring the original medical data obtained from multiple channels, a series of time point records are obtained, which can form a set of data based on time sequence, including at least a set of classified standardized data. These time point records include the patient's personal information and medical information and are configured with time points, such as medical conditions (which can be decomposed into symptoms), past history, marital history, family history, personal history, tests, examinations, drugs (or prescriptions), treatment, diagnosis and other categories. Each time point record is arranged on the timeline guided by the time point. In addition, the above personal information and medical information are only for the convenience of expression. In fact, there are no strict restrictions on the classification and role of the above information in the medical process.

[0044] For example, the course of a patient with ulcerative colitis is recorded as follows:

[0045] 1. December 1, 2018, [Condition] Diarrhea 10 times / day, chronic onset, small amount of stool each time, unformed loose stools, mucus, pus and blood in the stools.

[0046] 2. December 3, 2018, [Condition] Bloody stool 10 times / day, the amount of bloody stool is small, the stool contains dark red blood, and there is no thirst or fainting after bloody stool.

[0047] 3. On January 5, 2019, [Visit] Initial visit to the Department of Gastroenterology, Hospital A. [Examination] Colonoscopy, [Diagnosis] Diagnosis: ulcerative colitis. [Medication] Oral Chinese medicine, details unknown. [Treatment] Chinese medicine enema treatment, details unknown.

[0048] 4. On January 20, 2019, he went to the Department of Gastroenterology of Hospital A for a follow-up visit. His condition improved, and he had diarrhea 3 times a day. The amount of stool was not large each time, and the stool was unformed and loose, without mucus, pus or blood. He did not have blood in his stool again.

[0049] 5. On November 1, 2020, he went to the Department of Gastroenterology of Hospital B for a follow-up visit. His condition worsened, with diarrhea 8 times a day, and the amount of stool was not large each time. The stool was unformed and loose, with mucus, pus and blood. He had blood in his stool 8 times a day, with a small amount of blood in the stool, and the stool contained dark red blood. He did not feel thirsty or faint after the blood in the stool. [Laboratory tests] The white blood cell count in the blood routine test was increased, reaching 1.8x109 / L.

[0050] 6. On November 8, 2020, [visited] A hospital gastroenterology department for follow-up. [Condition] The condition worsened, diarrhea 10 times / day, each bowel movement was small, the stool was unformed loose stool, mucus, pus and blood. Blood in the stool 10 times / day, the amount of blood in the stool was small, the stool contained dark red blood, and there was no thirst or fainting after the blood in the stool. [Laboratory tests] The white blood cell count in the blood routine test increased, reaching 2.9x109 / L. [Drugs] Tinidazole and hydrocortisone were given, the details are unknown. [Treatment] Chinese medicine enema treatment, the details are unknown.

[0051] 7. On November 22, 2020, he went to the Department of Gastroenterology of Hospital A for a follow-up visit. His condition improved. He had diarrhea 3 times a day, and the amount of stool was not large each time. The stool was unformed and loose, without mucus, pus or blood. He did not have blood in the stool again. The white blood cell count in the blood routine test was increased, reaching 0.7x109 / L.

[0052] …

[0053] For the same time point record, [time point time] and [recording time] are not necessarily the same. For example: In the above example, the patient first went to the hospital for a consultation on January 5, 2019, but he became ill a month ago, so for the first time point record of diarrhea, [time point time] is December 1, 2018, and its [recording time] is January 5, 2019.

[0054] In the present application, the time point record is formed based on the initial necessary rules, which includes the initial time point record, subsequent time point record and last time point record with data association relationship.

[0055] The initial mandatory rule means that no matter under what circumstances the data is created or changed, the T1 first time point data must exist. This is called the initial mandatory rule for the time point record of the disease type. ① When the patient uses the remote consultation tool to enter the data, the patient-side data collection is expressed as the initial mandatory rule, that is, no matter what the entry is, it is necessary to confirm that the T1 first time point data exists before entering the subsequent process, such as Figure 2 ② When the medical end user uses the operating platform to add new data, whether creating a new medical record or adding symptoms to an existing medical record, it is required to enter the T1 first time point data first to ensure that the T1 data exists, such as Figure 3 ③ When data exchange is required through HIS system or other medical systems, or when our system extracts data from the system, the initial rules must still be met.

[0056] In this application, the condition is decomposed into symptoms, and the data after symptom deconstruction are arranged on the timeline, then each symptom will have a first time point record and a subsequent time point record. The first time point records of all symptoms of the current disease are summarized and defined as the initial time point record (called T1). Taking the current time point when the patient records the change of the condition as the timeline section, all symptom records of the disease at this point can be collected and summarized, and defined as the last time point record (called Tn). Only the last time point record is defined as the last time, and the remaining time point records are arranged in chronological order, and they together constitute the subsequent time point records.

[0057] Subsequent time points = remaining subsequent time points + last time point.

[0058] All time points = first time point + subsequent time points = first time point + (other subsequent time points + last time point).

[0059] The data of the last condition of the disease will change dynamically. According to the initial rules, as the patient continues to see the doctor, the position of the last time point keeps changing, and the data of each time axis section is constantly moving forward from the last time point to the data of the subsequent time point, which continuously forms the accumulation of multiple time point records, so that the dynamically changing disease data is collected. Due to the symptom deconstruction items established initially, the disease data collected in this way not only records the dynamic changes over time, but also can easily track and extract the changes of individual items, laying a superior data foundation for future data processing. For example: Suppose the [Frequency Count] of diarrhea in the disease time point record [Symptom] is selected as an indicator for monitoring the aggravation of the disease, and the [White Blood Cells] in the [Hematology Routine] in the laboratory time point record is selected as a comparison indicator, then we can clearly see that the patient's disease fluctuations and white blood cell values ​​are positively correlated. This is only a record of data. When similar data are analyzed on a large scale, perhaps in the process of treating ulcerative colitis, monitoring the changes in white blood cell values ​​is expected to become a new clinical observation indicator.

[0060] Data association refers to the linkage between various types of data. In the medical record, after the symptoms are deconstructed, the items with the same name under a single symptom form a front-to-back association on the time axis, thereby forming multi-point time axis longitudinal data to record and display dynamic changes in the disease, thereby improving the quality of the produced medical records and enhancing the possibility of further data application.

[0061] Through the above classification, time point establishment, dynamic end, deconstruction of project data association and other methods, this application has carried out basic standardization and structured processing of all medical record-related data. As the underlying foundation of the entire data structure, they can be called the time point record layer.

[0062] S2. Generate and display customized template information based on point-in-time records.

[0063] After obtaining the above-mentioned time point record, the customized template information is generated and displayed according to the request input by the user through the corresponding display interface. The display interface includes a record view interface and a time point view interface. When the template information is specifically generated, the customized template information is generated and displayed based on the preset output mode; in addition, the template information can also be modified based on the modification rules and the modification request input by the user through the above-mentioned display interface. For example, the template information is added, modified or deleted.

[0064] The user can perform some preset basic operations on the template information, including standard changes within the structure, free entry within the structure, free entry outside the structure, etc.

[0065] Standard changes within the structure: When the user calls a statement entry, the option box that appears can directly modify the internal storage data of this project, and the statement that appears after the selection is still the option of the project, displayed in a fixed position, and still has a complete standardized structure. The reason for this treatment is that the data collected by the remote consultation is provided by the patient, but because of the lack of medical knowledge, the actual options may change after the medical user's consultation, but the key points of the condition that need to be asked are actually the same. For example, a patient came to the clinic because of blood in the stool. When asked whether the amount of blood in the stool was large, the patient felt that it was a lot, so he chose to fill in "a lot of blood in the stool"; but after the doctor's questioning, it was found that the actual amount of blood in the stool was not large, and the medical record should record "less blood in the stool". This is called symptom analysis, which is a common situation in clinical practice and also a risk of pure online consultation. This application makes it convenient to modify the standard changes within the structure, and the selection can be changed by directly calling out the option box; more importantly, the data retains the original structure intact.

[0066] Free entry within the structure: In some items that cannot be fully standardized, this application retains the [other] option, allowing medical users to freely enter within the structure, which is called free entry within the structure. For example: the [predisposing factors] item asks the patient if there are any conditions that may have caused the illness before the onset of the disease, such as abdominal pain, asking whether there is food poisoning. This application standardizes some common symptoms and disease triggers and makes them into options, but the actual situations must vary greatly, and there will definitely be content records that are not in the standardized options; at this time, the medical user can fill it in the [other] option.

[0067] The advantage of this approach is that the data entered or collected, although not standardized, is still structured. For example: originally the patient filled in "no obvious trigger" in [Predisposing Factors], but after the doctor's questioning, the patient remembered that he had drunk cold wind, which may be related to the disease. The doctor decided to write "drinking cold wind" into the medical record; at this time, you can call up the [Predisposing Factors] option box and fill in the [Other] option directly. "Drinking cold wind" is not in the existing standardized options, but after the medical end user uses the free entry operation in the structure, it is determined to be under the [Predisposing Factors] project. Subsequent data processing follows the [Predisposing Factors] process, so the structuring is complete.

[0068] Free entry outside the structure: This application allows medical users to directly input or delete text content at any position on the operation layer interface, which is called free entry outside the structure. Due to the complexity of clinical conditions, even if the content of the medical record has been deeply deconstructed, it does not rule out the existence of content that cannot be attributed to the existing structure and needs to be recorded; or it may be because the medical user is not satisfied with the automatically generated sentence and wants to modify the sentence; in addition, due to the personal habits of the medical user and actual clinical convenience, it is likely that a small amount of content is recorded outside the structure. For example: The doctor will routinely ask about sleep and urination and defecation. When the patient's oliguria is not serious, the doctor may think that it is not necessary to record by adding oliguria symptoms; especially when it is believed that oliguria is secondary to low intake and can be improved by increasing water intake, it is generally simply supplemented with "oliguria" or "two bowel movements are OK". At this time, the doctor can directly move the cursor to the required position and enter the text.

[0069] The record view interface of this application is a display method that is closer to user habits, that is, it is more like a text medical record display. The point view interface is closer to the essence of point records, that is, it directly displays the medical record content in a structured form in a standard table-like manner. The common functions of the two interfaces include adding symptoms, deleting symptoms, and changing the main symptom.

[0070] ① Adding symptoms is to add symptoms that are not in the medical record data to the medical record. Its characteristic is that the newly added symptoms are added together with all the structural items under the symptom.

[0071] ② Deleting symptoms means deleting existing symptoms from the medical record, that is, clearing all structural items and data under the symptom. The operation of deleting symptoms is not revocable. After deleting a symptom, if you want to add it back using the add symptom function, you can only add structural items, and the data in all items needs to be re-entered.

[0072] The situation of deleting symptoms is mostly used when the symptoms reported by patients are too fragmented. For example, patients with anxiety often complain of more than a dozen discomforts at once. After the doctor's judgment, many symptoms are considered to be irrelevant to the condition and do not need to be treated, so they tend not to write them into the medical record. At this time, it is most convenient to delete the redundant symptoms and data together. In particular, one situation is explained. Because the medical end user is allowed to delete at any position in the free entry operation outside the structure, the entire symptom description statement can also be cleared through the free entry outside the structure. The medical record text display effect is the same as deleting symptoms. However, the deletion outside the structure only deletes the displayed text, and does not delete the symptoms or clear the data inside, so the symptom data actually still exists and will be clearly visible in the point-in-time view. This is also why the free entry operation outside the structure is meaningless in the point-in-time view, because it can only change the text content but not the structural data, and cannot actually delete it.

[0073] ③ Changing the main symptom means reselecting the main symptom from the existing symptoms and supplementing the corresponding data. This situation is often seen when the patient fills in the main symptom inaccurately, and the medical end user believes that it needs to be changed after analysis, because the main symptom record is more detailed and is also the first indicator to be paid attention to.

[0074] The time point view interface is an interface that highlights the time point concept and the internal structure of the symptom. In the time point view, pages are made with time as the cross section, and the time point record collection following the time is displayed on the page.

[0075] The collection display rules of the time point view page are as follows: a. All past medical histories, including past medical history, marriage and childbearing history, family history, and personal history, are displayed separately on the [Past Medical History] page, and are always at the forefront, unaffected by the timeline (because past medical history changes slowly, it may only change once every few years); b. The change or recording time of the main symptom is used as the time point for setting the page, and the first onset time of the main symptom is the time point of the first page; c. The first onset of the auxiliary symptom, regardless of the time, is displayed on the first page, but the onset time can be displayed separately; d. The auxiliary symptom Subsequent changes in the condition of the disease are mostly collected together with the main symptoms, so just follow the subsequent changes or recording time points of the main symptoms; if the last time of the auxiliary symptom is inconsistent with the last time of the main symptom, the time point will be added by default, and the main symptom will continue the previous data and be regarded as a new recording time point, and the auxiliary symptoms will follow the changes; e. Other types of time point records such as physical examination, laboratory tests and examinations, prescriptions, treatments, diagnoses, etc., follow the previous page closest to them (that is, follow the time point of the most recent change or record of the main symptom), and are displayed collectively on this page, and their time points are displayed separately.

[0076] The function buttons unique to the time point view include adding time points and deleting time points. Adding a time point means adding a new time point record, and deleting a time point means deleting an existing time point record. Because it is a direct modification to the underlying data layer, time point records of different categories will be added or deleted according to their belonging categories. Among them, the time point records of medical records are the most complex. Newly added or reduced symptom change time points may generate new timeline pages, especially changes in the main symptom time points, which will cause the timeline pages to be reassembled. Other categories of time point records do not cause the increase or decrease of pages, so they can be directly displayed in the corresponding position according to the page collection display rules.

[0077] The record view interface packages modular operations in a text-like display format. This approach is close to user experience and simple in display format, which can meet the basic needs of customers without the need for detailed processing of medical records. Therefore, the record view interface is a common interface in scenarios such as outpatient clinics and emergency departments that require quick processing of medical records. In addition, even in scenarios such as wards and scientific research that require detailed medical records, after the time point view interface is carefully processed, for the convenience of review, medical users will also return to the record view interface to check the customized template information content and may make some free entries to modify the language.

[0078] The unique function buttons of the record view interface include Write Current Illness and Write Past Illness. Write Current Illness is to put the specified past disease description in the past history into the current disease history. This situation is common when the past disease is related to the current condition, and the medical user believes that it needs to be recorded in the current disease history, so the operation of Write Current Illness can be used. Write Past Illness is the reverse operation of Write Current Illness, that is, put the content of the current disease history just grabbed back into the past history. It should be noted here that because all the past medical histories in the point-in-time view are displayed on the front-end past history page, and the content of the point-in-time page on the back timeline does not involve past history, the changes in the writing position of the past history cannot be displayed in the point-in-time view, and they can only be operations unique to the record view.

[0079] S3. Generate medical records based on customized template information.

[0080] The medical records here include formal medical records. The necessary condition for generating formal medical records is that they must be confirmed by the doctor. Therefore, it is necessary to generate formal medical records based on the record output request, that is, to complete the generation and output of medical records. The customized template information carrying the point-in-time record is modified by the doctor and confirmed and submitted in the form of a signature or electronic signature, thus forming a formal medical record with legal effect. Formal medical records are stored in an unstructured and non-modifiable text format.

[0081] This application takes customized template information as the main body, integrates the operation of template information and the modification function of text records on the corresponding interface, and makes it an integrated operation platform, such as Figure 4 The integrated operation platform is a tool for medical users to customize the debugging output rules. It can not only directly modify the underlying data, but also enrich the calling form of the underlying data and generate a variety of data templates to meet the needs of medical records.

[0082] In many cases, when the medical end user feels that the system's preset output rules basically meet the current medical record requirements, he can use the write-out function directly without making any changes to complete the text file. The write-out function is the termination button of the integrated operation platform, which indicates that the medical end user has completed the template debugging, data modification, and free text input language modification. Executing the write-out function will convert all the current contents in the operation console into text documents for storage, and at the same time save the current modified data in the structure in the background.

[0083] After the medical end user performs the write operation, the generated text format file becomes a formal medical record after being signed or electronically signed by the medical end user. Most of the existing remote consultation tools currently generate text format pre-medical records directly according to a certain template after the consultation, and then the doctor modifies it and signs it to become a medical record. This application integrates the operation of customized templates and the modification of text content into the integrated operation platform, so when the medical end user uses the write to enter the next step, the produced text medical record is actually a finished product and does not need to be modified. At the same time, in order to simplify the operation, if the medical end user uses an electronic signature, the signature step can be automatically integrated after the write function when the system is connected. For the medical end user, it only clicks once, but in fact completes the two nodes of producing the text medical record and signing to become a formal medical record.

[0084] Formal medical records are stored in text form. They are legally binding medical information and medical records. They can be accessed by relevant users (such as doctors, patients, lawyers, etc.) at any time in the system, but once sealed, they cannot be changed. The underlying data will be continuously updated during subsequent consultations and use. The data in the structure that has been used before may also be modified. The system only needs to record the modification log.

[0085] It can be seen from the above technical scheme that this embodiment provides a method for generating medical records. The method is applied to electronic devices. By disassembling and structuring the original medical data obtained from multiple channels, a time-sequence-based point record is obtained. The point record includes classified standardized data based on the initial necessary rules; customized template information is generated and displayed based on the point record; medical records are generated based on the customized template information, and the medical records include formal medical records. Through the above scheme, the underlying data of the medical record is arranged and evolved in a more orderly manner, and is called up and applied in the form of customized templates, so that users can operate data and templates according to actual conditions. Therefore, the processing efficiency of medical records can be greatly improved to meet a variety of different needs, and all applications built on this medical data structure are essentially upgraded, including but not limited to generating more accurate high-quality electronic medical records, performing data management operations according to user needs, generating customized medical research records, generating customized medical data analysis and reports, AI training in the medical field, etc. In another specific implementation of this embodiment, the following steps are also included, such as Figure 5 As shown:

[0086] S4. Output other medical records based on the point-in-time records.

[0087] The other medical records here include initial medical records, follow-up medical records, course medical records or major medical records. That is, after the user has corresponding needs and selects the corresponding record output rules, other application medical records matching the record output rules are output.

[0088] The generation of initial medical records is applicable to the following clinical situations: ① The patient comes to the hospital for the first time for a certain disease; ② The patient is not visiting the hospital for the first time, but the disease condition has changed significantly or worsened, and the doctor believes that it is necessary to review the onset of the disease to better record the diagnosis and treatment process; ③ The patient has been to other hospitals for treatment, but there is a lack of detailed and reliable diagnosis and treatment records, and the doctor believes that it is best to leave a reliable medical record again; ④ Other doctors believe that it is necessary to review the onset of the disease. Output rules for initial medical records: Extract ① The medical record type time point records of the first time point of T1 and the last time point of Tn, ② The last first diagnosis time point record made for the first time, ③ The last medication time point record, ④ The unreported laboratory and examination time point record; the above data are converted and spliced ​​into medical terms according to the rules within their categories, and then reorganized and output in chronological order.

[0089] The generation of follow-up medical records is applicable to the following clinical situations: ① Patients come to the hospital for follow-up; ② Other doctors believe that the situation can be treated as a follow-up. The output rules of follow-up medical records are as follows: Extract ① The time point record of the last Tn time point of the medical condition record, ② The time point record of the last first diagnosis made for the first time, ③ The time point record of the last medication, and ④ The time point record of unreported tests and examinations; After the above data are converted and spliced ​​into medical terms according to the rules within their categories, they are reorganized and output in chronological order.

[0090] The generation of medical records is applicable to the following clinical situations: ① Routine medical records of inpatients on a daily basis except for the first admission day; ② Temporary medical records when the inpatient's condition fluctuates dramatically. Output rules for medical records: Extract ① Time point records of the condition record category at the last time point of Tn, ② Time point records of unreported tests and examinations; convert and splice the above data into medical terms according to the rules within their categories, and reorganize and output them in chronological order.

[0091] The generation of medical records is applicable to the following clinical situations: ① The first detailed medical record of an inpatient on the day of admission, commonly known as the "medical record"; ② Other situations where doctors believe that it is necessary to review the onset of illness and write it in the medical record. The output rules of the medical record are: extract ① the medical record of the first time point T1 and the last time point Tn, ② all time point records marked as "key points", convert and splice them into medical terms according to the rules within their categories, and reorganize and output them in chronological order.

[0092] This application also has a medical record packaging function, which is a function specially made for customized generation of large medical records. Its purpose is to enable medical users to mark various time point records as "key points", and then when the large medical record generation function is used again, all time point records marked as "key points" will be written into the newly generated large medical record according to preset rules. Since the "key point" mark is a direct modification of the underlying data, it exists for a long time with the condition data. When the large medical record needs to be generated again next time, the "key point" marks made before will all be in effect. This means that for the medical records of patients with long-term chronic diseases, the technical solution provided by this application can not only quickly generate a high-quality customized medical record, but also provide a quick browsing function for important past data, which can greatly improve the processing efficiency of medical records of patients with long-term chronic diseases.

[0093] The flow chart and block diagram in the accompanying drawings illustrate the possible architecture, function and operation of the system, method and computer program product according to various embodiments of the present disclosure. In this regard, each square box in the flow chart or block diagram can represent a module, a program segment or a part of a code, and the module, the program segment or a part of the code contains one or more executable instructions for realizing the specified logical function. It should also be noted that in some implementations as replacements, the functions marked in the square box can also occur in a sequence different from that marked in the accompanying drawings. For example, two square boxes represented in succession can actually be executed substantially in parallel, and they can sometimes be executed in the opposite order, depending on the functions involved. It should also be noted that each square box in the block diagram and / or flow chart, and the combination of the square boxes in the block diagram and / or flow chart can be implemented with a dedicated hardware-based system that performs a specified function or operation, or can be implemented with a combination of dedicated hardware and computer instructions.

[0094] Although operations are depicted in a particular order, this should not be understood as requiring that the operations be performed in the particular order shown or in a sequential order.Multitasking and parallel processing may be advantageous under certain circumstances.

[0095] It should be understood that the various steps described in the method embodiments of the present disclosure may be performed in different orders and / or in parallel. In addition, the method embodiments may include additional steps and / or omit the steps shown. The scope of the present disclosure is not limited in this respect.

[0096] Computer program code for performing the operations of the present disclosure may be written in one or more programming languages ​​or a combination thereof, including, but not limited to, object-oriented programming languages, such as Java, Smalltalk, C++, and conventional procedural programming languages, such as C or similar programming languages. The program code may be executed entirely on the user's computer, partially on the user's computer, as a separate software package, partially on the user's computer and partially on a remote computer, or entirely on a remote computer or server. In cases involving a remote computer, the remote computer may be connected to the user's computer through any type of network, including a local area network (LAN) or a wide area network (WAN), or may be connected to an external computer.

[0097] Figure 6 This is a block diagram of a medical record generation device according to an embodiment of the present application.

[0098] like Figure 6 As shown, the generating device provided in this embodiment is applied to an electronic device, and is used to generate corresponding medical records based on the original medical information data. The electronic device can be understood as a computer, server, cloud platform, etc. with data computing and information processing capabilities. The generating device specifically includes a time point recording module 10, a first generating module 20, and a second generating module 30.

[0099] The point-in-time recording module is used to obtain time-sequence classified standardized data point-in-time records based on the original medical information data.

[0100] By disassembling and structuring the original medical data obtained from multiple channels, a series of time point records are obtained, which can form a set of data based on time sequence. These time point records include the patient's personal information and medical information and are configured with time points, such as medical conditions (which can be decomposed into symptoms), past medical history, marriage and childbearing history, family history, personal history, tests, examinations, drugs (or prescriptions), treatments, diagnoses, etc. Each time point record is arranged on the timeline guided by the time point.

[0101] The first generating module is used to generate and display customized template information based on the time point record.

[0102] After obtaining the above-mentioned time point record, the customized template information is generated and displayed according to the request input by the user through the corresponding display interface. The display interface includes a record view interface and a time point view interface. When the template information is specifically generated, the customized template information is generated and displayed based on the preset output mode; in addition, the template information can also be modified based on the modification rules and the modification request input by the user through the above-mentioned display interface. For example, the template information is added, modified or deleted.

[0103] The second generating module is used to generate medical records based on customized template information.

[0104] The medical records here include formal medical records. The necessary condition for generating formal medical records is that they must be confirmed by the doctor. Therefore, the formal record needs to be generated based on the record output request, that is, the generation and output of the medical record is completed. The customized template information carrying the point-in-time record is modified by the doctor and confirmed and submitted in the form of a signature or electronic signature, thus forming a formal medical record with legal effect.

[0105] It can be seen from the above technical scheme that this embodiment provides a medical record generation device, which is applied to electronic devices, specifically, by disassembling and structuring the original medical data obtained from multiple channels, a time point record based on time sequence is obtained, and the time point record includes classified standardized data based on the initial necessary rules; customized template information is generated and displayed based on the time point record; medical records are generated based on the customized template information, and the medical records include formal medical records. Through the above scheme, the underlying data of the medical record is arranged and evolved in a more orderly manner, and is called and applied in the form of a customized template, so that users can operate the data and templates according to actual conditions, so that the processing efficiency of medical records can be greatly improved, meet a variety of different needs, and essentially upgrade all applications built on this medical data structure, including but not limited to generating more accurate high-quality electronic medical records, performing data management operations according to user needs, generating customized medical research records, generating customized medical data analysis and reports, AI training in the medical field, etc.

[0106] In another specific implementation of this embodiment, a record output module 40 is also included. Figure 7 As shown:

[0107] The record output module is used to output medical records for other applications based on point-in-time records.

[0108] The other application medical records here include initial medical records, follow-up medical records, course medical records or major medical records. That is, after the user has corresponding needs and selects the corresponding record output rules, other application medical records matching the record output rules are output.

[0109] The units involved in the embodiments described in the present disclosure may be implemented by software or hardware. The name of a unit does not limit the unit itself in some cases. For example, the first acquisition unit may also be described as a "unit for acquiring at least two Internet Protocol addresses".

[0110] The functions described above herein may be performed at least in part by one or more hardware logic components. For example, without limitation, exemplary types of hardware logic components that may be used include: field programmable gate arrays (FPGAs), application specific integrated circuits (ASICs), application specific standard products (ASSPs), systems on chips (SOCs), complex programmable logic devices (CPLDs), and the like.

[0111] Figure 8 A block diagram of an electronic device according to an embodiment of the present application.

[0112] Reference below Figure 8 , which shows a schematic diagram of the structure of an electronic device suitable for implementing the embodiments of the present disclosure. The terminal device in the embodiments of the present disclosure may include, but is not limited to, mobile terminals such as mobile phones, laptop computers, digital broadcast receivers, PDAs (personal digital assistants), PADs (tablet computers), PMPs (portable multimedia players), vehicle-mounted terminals (such as vehicle-mounted navigation terminals), etc., and fixed terminals such as digital TVs, desktop computers, etc. The electronic device is only an example and should not bring any limitation to the functions and scope of use of the embodiments of the present disclosure.

[0113] The electronic device may include a processing device (e.g., a central processing unit, a graphics processing unit, etc.) 501, which can perform various appropriate actions and processes according to a program stored in a read-only memory ROM 502 or a program loaded from an input device 506 into a random access memory RAM 503. In the RAM, various programs and data required for the operation of the electronic device are also stored. The processing device, ROM, and RAM are connected to each other via a bus 504. An input / output (I / O) interface 505 is also connected to the bus 504.

[0114] Typically, the following devices may be connected to the I / O interface: input devices including, for example, a touch screen, a touchpad, a keyboard, a mouse, a camera, a microphone, an accelerometer, a gyroscope, etc.; output devices 507 including, for example, a liquid crystal display (LCD), a speaker, a vibrator, etc.; storage devices 508 including, for example, a magnetic tape, a hard disk, etc.; and communication devices 509. The communication device 509 may allow the electronic device to communicate with other devices wirelessly or by wire to exchange data. Although the figure shows an electronic device with various devices, it should be understood that it is not required to implement or have all the devices shown. More or fewer devices may be implemented or have alternatively.

[0115] This embodiment also provides a computer-readable storage medium embodiment.

[0116] The above storage medium is applied to an electronic device and carries one or more computer programs. When the above one or more computer programs are executed by the electronic device, the electronic device disassembles and structures the original medical data obtained from multiple channels to obtain a time point record based on time sequence, and the time point record includes classified standardized data based on the initial necessary rules; generates and displays customized template information based on the time point record; generates medical records based on the customized template information, and the medical records include formal medical records. Through the above scheme, the underlying data of the medical record is arranged and evolved in a more orderly manner, and is called and applied in the form of customized templates, so that users can operate data and templates according to actual conditions, thereby greatly improving the processing efficiency of medical records, meeting a variety of different needs, and essentially upgrading all applications built on this medical data structure, including but not limited to generating more accurate high-quality electronic medical records, performing data management operations according to user needs, generating customized medical research records, generating customized medical data analysis and reports, AI training in the medical field, etc.

[0117] It should be noted that the computer-readable medium disclosed above may be a computer-readable signal medium or a computer-readable storage medium or any combination of the above two. The computer-readable storage medium may be, for example, but not limited to, an electrical, magnetic, optical, electromagnetic, infrared, or semiconductor system, device or device, or any combination of the above. More specific examples of computer-readable storage media may include, but are not limited to: an electrical connection with one or more wires, a portable computer disk, a hard disk, a random access memory (RAM), a read-only memory (ROM), an erasable programmable read-only memory (EPROM or flash memory), an optical fiber, a portable compact disk read-only memory (CD-ROM), an optical storage device, a magnetic storage device, or any suitable combination of the above.

[0118] In the present disclosure, a computer-readable storage medium may be any tangible medium containing or storing a program that may be used by or in combination with an instruction execution system, apparatus, or device. In the present disclosure, a computer-readable signal medium may include a data signal propagated in a baseband or as part of a carrier wave, which carries a computer-readable program code. Such propagated data signals may take a variety of forms, including but not limited to electromagnetic signals, optical signals, or any suitable combination of the above. A computer-readable signal medium may also be any computer-readable medium other than a computer-readable storage medium, which may send, propagate, or transmit a program for use by or in combination with an instruction execution system, apparatus, or device. The program code contained on the computer-readable medium may be transmitted using any suitable medium, including but not limited to: wires, optical cables, RF (radio frequency), etc., or any suitable combination of the above.

[0119] The various embodiments in this specification are described in a progressive manner, and each embodiment focuses on the differences from other embodiments. The same or similar parts between the various embodiments can be referenced to each other.

[0120] Although the preferred embodiments of the present invention have been described, those skilled in the art may make additional changes and modifications to these embodiments once they have learned the basic creative concept. Therefore, the appended claims are intended to be interpreted as including the preferred embodiments and all changes and modifications that fall within the scope of the embodiments of the present invention.

[0121] Finally, it should be noted that, in this article, relational terms such as first and second, etc. are only used to distinguish one entity or operation from another entity or operation, and do not necessarily require or imply any such actual relationship or order between these entities or operations. Moreover, the terms "include", "comprise" or any other variants thereof are intended to cover non-exclusive inclusion, so that a process, method, article or terminal device including a series of elements includes not only those elements, but also other elements not explicitly listed, or also includes elements inherent to such process, method, article or terminal device. In the absence of further restrictions, the elements defined by the sentence "comprise a ..." do not exclude the existence of other identical elements in the process, method, article or terminal device including the elements.

[0122] The technical solution provided by the present invention is introduced in detail above. Specific examples are used in this article to illustrate the principle and implementation mode of the present invention. The description of the above embodiments is only used to help understand the method of the present invention and its core idea. At the same time, for those skilled in the art, according to the idea of ​​the present invention, there will be changes in the specific implementation mode and application scope. In summary, the content of this specification should not be understood as limiting the present invention.

Claims

1. A method for generating medical records, applied to an electronic device, characterized in that: The generation method comprises the steps of: By disassembling and structuring the original medical data obtained from multiple channels, a time point record based on time sequence is obtained, and the time point record includes classified and standardized data based on the initial necessary rules; Based on the data call and operation request input by the user through the display interface, generate and display customized template information based on the time point record; Based on a record generation request from a user, a medical record is generated based on the customized template information, wherein the medical record includes a formal medical record.

2. The generation method according to claim 1, characterized in that: The time point records include an initial time point record, a subsequent time point record and a final time point record which are formed based on a preset initial rule and have a data association relationship.

3. The generation method according to claim 1, characterized in that: The display interface includes a record view interface and a time point view interface.

4. The generation method according to claim 3, characterized in that: The generating and displaying of customized template information comprises the steps of: Generate and display the customized template information based on a preset output mode; The customized template information is added, modified or deleted based on the modification rules and the modification request input by the user through the display interface.

5. The generation method according to claim 1, characterized in that: The user-based record generation request generates a medical record based on the customized template information and the time point record, wherein the medical record includes a formal medical record, including the steps of: Receiving the record generation request using an integrated operating platform; The integrated operating platform is used to generate a text document based on the customized template and the time point record, and the text document is used for the user to call and generate the formal medical record.

6. The generation method according to any one of claims 1 to 5, characterized in that: Also includes the steps: The record output rules are selected according to the user's needs, and the initial medical record, follow-up medical record, medical course record or major medical record are generated and output based on the time point records.

7. A medical record generation device, applied to an electronic device, characterized in that: The generating device comprises: A time point record module is configured to obtain time point records based on time sequence by disassembling and structuring the original medical data obtained from multiple channels, wherein the time point records include classified and standardized data based on initial rules; A first generating module is configured to generate and display customized template information based on the time point record based on the data call and operation request input by the user through the display interface; The second generating module is configured to generate a medical record based on the user's record generation request and based on the customized template information, wherein the medical record includes a formal medical record.

8. The generating device according to claim 7, characterized in that Also includes: The record output module is configured to select record output rules according to user needs, and generate and output initial medical records, follow-up medical records, medical history records or major medical records based on the time point records.

9. An electronic device, characterized in that: The method comprises at least one processor and a memory connected to the processor, wherein: The memory is used to store computer programs or instructions; The processor is used to execute the computer program or instruction so that the electronic device implements the method for generating a medical record according to any one of claims 1 to 6.

10. A storage medium, applied to an electronic device, characterized in that: The storage medium carries one or more computer programs, and the one or more computer programs can be executed by the electronic device, so that the electronic device implements the method for generating a medical record as described in any one of claims 1 to 6.

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