Medical information management method and device

Abstract

The invention discloses a medical information management method and device, and relates to the field of medical information processing, and the method comprises the steps: obtaining the research information of a clinical research project matched with the role information from a clinical research project management system according to the role information of a doctor who logs in the system at present, the research information comprises a visit plan and a clinical research medical record template; when it is determined that the current patient is a subject according to the received identifier of the current patient, displaying a clinical diagnosis and treatment selection control and a clinical research selection control; in response to a selection operation for the diagnosis and treatment selection control, outputting a corresponding clinical diagnosis and treatment medical record template; or in response to a selection operation for the clinical research selection control, outputting the visit plans, and loading the clinical research medical record template under each visit plan; and receiving the current medical record information of the subject, filling the current medical record information into the corresponding medical record template to obtain the current medical record, and storing the current medical record to the database, so that the recording efficiency of the medical record is improved.

Description

Technical Field

[0001] This application relates to the field of medical information processing, and particularly to a medical information management method and device. Background Art

[0002] A clinical research project refers to a systematic study on drugs, medical devices, or other treatment methods in humans (patients or healthy volunteers) to confirm or discover their clinical, pharmacological, and other pharmacodynamic effects, adverse reactions, as well as absorption, distribution, metabolism, and excretion, with the aim of determining the safety and effectiveness of new therapies.

[0003] In a clinical research project, a visit refers to a face-to-face communication or examination between the research team and the subject at a predetermined time, which plays a crucial role in ensuring the scientific nature of the trial, protecting the safety and rights of the subject, and improving the quality of the trial.

[0004] Currently, when seeing patients, doctors will log in to the clinical diagnosis and treatment electronic medical record system to record the medical records of each patient. When the patient is a subject participating in a clinical research project, the doctor needs to log in to the clinical research project management system and record the clinical research medical records of the subject according to their own recording habits in the clinical research project management system.

[0005] This solution will make the doctor's operation more complex, requiring switching between two systems, and the clinical research medical records largely depend on the doctor's personal habits, resulting in insufficient comprehensiveness and depth of the content of the clinical research medical records and possibly missing key information. Summary of the Invention

[0006] The purpose of this application is to provide a medical information management method and device, which can avoid doctors switching between systems and improve the recording efficiency of medical records.

[0007] To achieve the above purpose, this application provides the following solutions:

[0008] In the first aspect, this application provides a medical information management method, which is applied to a clinical diagnosis and treatment electronic medical record system. The medical information management method includes:

[0009] Obtain research information of a clinical research project that matches the role information from the clinical research project management system according to the role information of the doctor currently logged in to the system. The research information includes: visit plan and clinical research medical record template;

[0010] Receive the identifier of the current patient. When it is determined that the current patient is a subject according to the identifier of the current patient, display a clinical diagnosis and treatment selection control and a clinical research selection control; wherein, the subject is a patient who has joined the clinical research project;

[0011] In response to a selection operation on the diagnosis and treatment selection control, output the corresponding clinical diagnosis and treatment medical record template; or, in response to a selection operation on the clinical research selection control, output the visit plan, and load the clinical research medical record template under each plan item of the visit plan;

[0012] Receive the current medical record information of the subject, fill the current medical record information into the corresponding medical record template to obtain the current medical record, and save the current medical record to the database.

[0013] In a second aspect, the present application provides a medical information management device, which is applied to a clinical diagnosis and treatment electronic medical record system. The medical information management device includes:

[0014] An acquisition module, configured to acquire research information of a clinical research project that matches the role information from a clinical research project management system according to the role information of the doctor currently logged in to the system. The research information includes: a visit plan and a clinical research medical record template;

[0015] A receiving module, configured to receive the identifier of the current patient, and display a clinical diagnosis and treatment selection control and a clinical research selection control when it is determined that the current patient is a subject according to the identifier of the current patient; wherein, the subject is a patient who has joined the clinical research project;

[0016] An output module, configured to, in response to a selection operation on the diagnosis and treatment selection control, output the corresponding clinical diagnosis and treatment medical record template; or, in response to a selection operation on the clinical research selection control, output the visit plan, and load the clinical research medical record template under each plan item of the visit plan;

[0017] A saving module, configured to receive the current medical record information of the subject, fill the current medical record information into the corresponding medical record template to obtain the current medical record, and save the current medical record to the database.

[0018] According to the specific embodiments provided by the present application, the following technical effects are disclosed in the present application:

[0019] The present application provides a medical information management method and apparatus. The medical information management method is applied to a clinical diagnosis and treatment electronic medical record system. The medical information management method includes: obtaining research information of a clinical research project matching the role information from a clinical research project management system according to the role information of the doctor currently logged in to the system, where the research information includes: a visit plan and a clinical research medical record template; receiving an identifier of the current patient, and when it is determined that the current patient is a subject according to the identifier of the current patient, displaying a clinical diagnosis and treatment selection control and a clinical research selection control; where a subject is a patient who has joined a clinical research project; in response to a selection operation on the diagnosis and treatment selection control, outputting a corresponding clinical diagnosis and treatment medical record template; or, in response to a selection operation on the clinical research selection control, outputting a visit plan and loading a clinical research medical record template under each planned item of the visit plan; receiving the current medical record information of the subject, filling the current medical record information into the corresponding medical record template to obtain the current medical record, and saving the current medical record to a database. Generally, when referring to a clinical diagnosis and treatment electronic medical record system, it is defaulted to include the functions of doctors writing medical records and giving medical orders, that is, the functions that doctors use when patients go to the hospital for treatment. However, the clinical diagnosis and treatment electronic medical record system only includes clinical diagnosis and treatment medical records, that is, the medical record materials of patients' daily visits to the hospital, and does not include clinical research medical records. When the current patient is a subject of a clinical research project, the doctor needs to record his clinical research medical record. At this time, the doctor needs to log in to the clinical research project management system and then record the clinical research medical record of the subject in the clinical research project management system. For doctors, they need to switch between two systems, which will make the doctor's operation more complicated, waste the doctor's consultation time, and make the recording efficiency of medical records lower. In the present disclosure, doctors can complete the recording of both clinical diagnosis and treatment medical records and clinical research medical records only in the clinical diagnosis and treatment electronic medical record system, saving the doctor's time, improving the recording efficiency of medical records, and in the related art, when recording clinical research medical records, there is no unified template and it is recorded based on the doctor's habits, which will make the recorded content less standardized and there may also be problems of missing content. In the present disclosure, a clinical research medical record template is set, so that the recorded clinical research medical records can be more standardized, unified and complete, thus comprehensively ensuring the integrity and accuracy of the data of clinical research projects. BRIEF DESCRIPTION OF THE DRAWINGS

[0020] In order to more clearly illustrate the technical solutions in the embodiments of the present application or the prior art, the following will briefly introduce the drawings required to be used in the embodiments. Obviously, the drawings in the following description are only some embodiments of the present application. For those of ordinary skill in the art, without creative efforts, other drawings can be obtained based on these drawings.

[0021] Figure 1 is a flowchart of a medical information management method shown according to an exemplary embodiment;

[0022] Figure 2 Schematic template one of the clinical research medical record template provided by an embodiment of the present application;

[0023] Figure 3 Schematic template two of the clinical research medical record template provided by an embodiment of the present application;

[0024] Figure 4 Schematic template three of the clinical research medical record template provided by an embodiment of the present application;

[0025] Figure 5 Schematic diagram of the display interface of the clinical diagnosis and treatment electronic medical record system provided by an embodiment of the present application Figure 1 ;

[0026] Figure 6 Schematic diagram of the display interface of the clinical diagnosis and treatment electronic medical record system provided by an embodiment of the present application Figure 2 ;

[0027] Figure 7 Schematic diagram of the display interface of the clinical diagnosis and treatment electronic medical record system provided by an embodiment of the present application Figure 3 ;

[0028] Figure 8 Schematic diagram of the display interface of the clinical diagnosis and treatment electronic medical record system provided by an embodiment of the present application Figure 4 ;

[0029] Figure 9 Schematic diagram of the display interface of the clinical diagnosis and treatment electronic medical record system provided by an embodiment of the present application Figure 5 ;

[0030] Figure 10 Schematic diagram of the display interface of the clinical diagnosis and treatment electronic medical record system provided by an embodiment of the present application Figure 6 ;

[0031] Figure 11 Schematic diagram of the display interface of the clinical diagnosis and treatment electronic medical record system provided by an embodiment of the present application Figure 7 ;

[0032] Figure 12 Schematic diagram of the display interface of the clinical diagnosis and treatment electronic medical record system provided by an embodiment of the present application Figure 8 ;

[0033] Figure 13 Schematic diagram of the functional modules of a medical information management device provided by an embodiment of the present application;

[0034] Figure 14 Schematic diagram of the structure of a computer device provided by an embodiment of the present application. Detailed implementation manners

[0035] The following will clearly and completely describe the technical solutions in the embodiments of the present application with reference to the accompanying drawings in the embodiments of the present application. Obviously, the described embodiments are only a part of the embodiments of the present application, rather than all the embodiments. Based on the embodiments in the present application, all other embodiments obtained by those of ordinary skill in the art without creative efforts shall fall within the protection scope of the present application.

[0036] To make the above objects, features, and advantages of the present application more obvious and understandable, the present application will be further described in detail below with reference to the accompanying drawings and specific embodiments.

[0037] Figure 1 is a flowchart of a medical information management method shown according to an exemplary embodiment. The medical information management method is applied to a clinical diagnosis and treatment electronic medical record system, such as Figure 1 shown, the medical information management method includes the following steps S101 - S104:

[0038] In step S101, research information of a clinical research project that matches the role information is obtained from the clinical research project management system according to the role information of the doctor currently logged in to the system. The research information includes: visit plan and clinical research medical record template.

[0039] In one embodiment, step S101 specifically includes the following sub - steps S1011 - S1013:

[0040] S1011. Obtain role information.

[0041] After the doctor logs in to the clinical diagnosis and treatment electronic medical record system using his / her login account and password, the clinical diagnosis and treatment electronic medical record system will obtain the role information of the doctor corresponding to the login account. For example, the doctor's role information includes the following information: name, gender, age, department, whether he / she is a research doctor, etc.

[0042] Among them, the clinical diagnosis and treatment electronic medical record system can obtain the role information of the doctor corresponding to the login account from the local database or from the cloud database.

[0043] Among them, the scenario where the doctor logs in to the clinical diagnosis and treatment electronic medical record system using his / her login account and password can be: the doctor logs in to the clinical diagnosis and treatment electronic medical record system using his / her login account and password when seeing patients in the outpatient clinic.

[0044] S1012. Send the role information to the clinical research project management system.

[0045] S1013. Receive the research information of the clinical research project that matches the role information sent by the clinical research project management system.

[0046] The research information of the clinical research project is sent by the clinical research project management system after detecting that it stores a clinical research project that matches the role information according to the role information.

[0047] After the clinical diagnosis and treatment electronic medical record system obtains the role information of the doctor currently logged in to the system, it will send the role information of the doctor currently logged in to the system to the clinical research project management system, so that the clinical research project management system can detect whether it stores a clinical research project that matches the role information according to the role information.

[0048] If the clinical research project management system detects that it stores a clinical research project that matches the role information according to the role information, the clinical research project management system sends the research information of the clinical research project that matches the role information to the clinical diagnosis and treatment electronic medical record system. If the clinical research project management system detects that it does not store a clinical research project that matches the role information according to the role information, the clinical research project management system sends a no-clinical-research-project prompt message to the clinical diagnosis and treatment electronic medical record system.

[0049] In one embodiment, if the research information of the clinical research project sent by the clinical research project management system is received, then steps S102 - S104 are continued; if the no-clinical-research-project prompt message sent by the clinical research project management system is received, it indicates that the doctor currently logged in to the system has no participated clinical research projects. Then, when diagnosing and treating patients subsequently, only the clinical diagnosis and treatment selection controls as shown in Figure 6 are displayed in the clinical diagnosis and treatment electronic medical record system.

[0050] For example, the clinical research project management system can store the mapping relationship between the doctor's role information and the permission information of the clinical research project, and the research information of the clinical research project. Among them, the doctor's role information includes: name, gender, age, department, whether being a research doctor, etc. The permission information of the clinical research project includes project number, project name, undertaking department, name of the principal investigator (PI), etc. The clinical research project management system matches the corresponding permission information of the clinical research project according to the doctor's role information sent by the clinical diagnosis and treatment electronic medical record system. After matching the permission information of the clinical research project, it obtains the research information corresponding to the clinical research project based on the permission information of the clinical research project.

[0051] Only when the clinical research project management system matches a clinical research project for the doctor currently logged in to the system, that is, the doctor currently logged in to the system is a research doctor for a certain clinical research project and has undertaken the clinical research project, will the clinical research project management system send the research information of the matched clinical research project to the clinical diagnosis and treatment electronic medical record system. Otherwise, the clinical research project management system will not send any research information of clinical research projects to the clinical diagnosis and treatment electronic medical record system.

[0052] Among them, the visit plan is a complete visit process of a clinical research project. For example, it can include: the process of reproducing project informed consent, screening period examinations, inclusion and exclusion confirmation, random drug administration, C1D1 and other planned items.

[0053] In the present disclosure, the clinical research medical record template may include: basic information of the subject, medical history of the subject, test and examination records, concomitant medications, adverse events, etc.; while the clinical diagnosis and treatment medical record template may include: basic information of the patient, medical history of the patient, and test and examination records.

[0054] Among them, the basic information of the subject includes: the name, gender, date of birth, age, department of visit, outpatient number, visit date, visit name of the subject. Among them, the visit name is a planned item in the visit plan. For example, if the current visit is inclusion and exclusion confirmation, then the visit name is inclusion and exclusion confirmation.

[0055] The basic information of the patient includes: the name, gender, date of birth, age, department of visit, outpatient number, and date of visit of the patient.

[0056] Among them, the clinical research medical record templates corresponding to the various planned items of the visit plan can be general templates, that is, the clinical research medical record templates corresponding to the various planned items of the visit plan are all the same. As Figure 2 shown, it should be noted that in order to distinguish the clinical research medical record templates corresponding to each planned item, the name of the planned item can be added to the first line of the clinical research medical record template corresponding to each planned item. As Figure 3 shown, the name of the GCP project screening period medical record is added to the first line of this clinical research medical record template, indicating that this clinical research medical record template corresponds to the screening period of the GCP project. The clinical research medical record templates corresponding to the various planned items of the visit plan can also be personalized templates, that is, the clinical research medical record templates corresponding to each planned item of the visit plan can be different. As Figure 4 shown is the clinical research medical record template corresponding to the process of reproducing project informed consent.

[0057] In step S102, receive the identifier of the current patient. When it is determined that the current patient is a subject based on the identifier of the current patient, display the clinical diagnosis and treatment selection control and the clinical research selection control; among them, the subject is a patient who has joined a clinical research project.

[0058] When a patient is receiving medical treatment in a doctor's consulting room, after placing the medical visit card on the card reader, the card reader can read the identification of the current patient in the medical visit card. Then the card reader sends the identification of the current patient to the clinical diagnosis and treatment electronic medical record system. After receiving the identification of the current patient, the clinical diagnosis and treatment electronic medical record system will check whether the current patient is a subject based on the identification of the current patient. If the patient is a subject, both the clinical diagnosis and treatment selection control and the clinical research selection control will be displayed. Taking the clinical diagnosis and treatment including the first visit and the follow-up visit as an example, the first visit selection control, the follow-up visit selection control and the GCP selection control as shown in Figure 5 will be displayed. Among them, the GCP selection control is the clinical research selection control.

[0059] Among them, the clinical diagnosis and treatment electronic medical record system can detect whether the identification of the current patient is stored in the database by using the identification of the patient corresponding to the subject stored in its own database. If it is stored in the database, it is determined that the current patient is a subject. The clinical diagnosis and treatment electronic medical record system can also send the identification of the current patient to the clinical research project management system. The clinical research project management system detects whether the identification of the current patient is stored in the database by using the identification of the patient corresponding to the subject stored in its own database. If it is stored in the database, it is determined that the current patient is a subject, and sends an indication message that the current patient is a subject to the clinical diagnosis and treatment electronic medical record system. After receiving the indication message that the current patient is a subject sent by the clinical research project management system, the clinical diagnosis and treatment electronic medical record system determines that the current patient is a subject.

[0060] In another implementable manner, if it is determined that the current patient is not a subject according to the identification of the current patient, only the clinical diagnosis and treatment selection control will be displayed. Taking the clinical diagnosis and treatment including the first visit and the follow-up visit as an example, the first visit selection control and the follow-up visit selection control as shown in Figure 6 will be displayed. At this time, the GCP selection control as shown in Figure 5 will not be displayed.

[0061] In the present disclosure, the clinical research medical record template can be configured in the clinical research project management system according to the content of the research protocol in the clinical research project.

[0062] In step S103, in response to the selection operation on the diagnosis and treatment selection control, the corresponding clinical diagnosis and treatment medical record template is output; or, in response to the selection operation on the clinical research selection control, a visit plan is output, and the clinical research medical record template is loaded under each plan item of the visit plan.

[0063] In one embodiment, step S103 includes the following sub-steps S1031 - S1035:

[0064] S1031. Detect whether the historical medical records of the subject are saved in the database; the historical medical records for diagnosis and treatment include at least one of the following: clinical diagnosis and treatment historical medical records and clinical research historical medical records.

[0065] S1032. If the clinical diagnosis and treatment historical medical records are not saved, in response to the selection operation on the diagnosis and treatment selection control, output the corresponding clinical diagnosis and treatment medical record template.

[0066] Among them, the clinical diagnosis and treatment historical medical records may include initial diagnosis and treatment historical medical records and follow-up diagnosis and treatment historical medical records.

[0067] If the initial diagnosis and treatment historical medical records are not saved in the database, it indicates that the current patient is visiting for the first time, and continue according to Figure 5 the example of Figure 7 As shown, when the doctor selects the initial diagnosis, the corresponding clinical diagnosis and treatment medical record template for the initial diagnosis will be displayed in the medical record display area; as Figure 8 shown, when the doctor selects the follow-up diagnosis, the corresponding clinical diagnosis and treatment medical record template for the follow-up diagnosis will be displayed in the medical record display area. In the examples of Figure 7 and Figure 8 the clinical diagnosis and treatment medical record template corresponding to the initial diagnosis and the clinical diagnosis and treatment medical record template corresponding to the follow-up diagnosis are the same, but in the actual scenario, the clinical diagnosis and treatment medical record template corresponding to the initial diagnosis and the clinical diagnosis and treatment medical record template corresponding to the follow-up diagnosis may also be different, and the present disclosure does not limit it.

[0068] S1033. If the clinical research historical medical records are not saved, in response to the selection operation on the clinical research selection control, output the plan item selection controls for each plan item of the visit plan, and in response to the selection operation on the target plan item selection control, output the clinical research medical record template for the plan item corresponding to the target plan item selection control.

[0069] If the clinical research historical medical records are not saved in the database, it indicates that the current patient is visiting for the first time, and continue according to Figure 5 the example of Figure 9 taking the visit plan including: project informed consent reproduction process, screening period examination, inclusion and exclusion confirmation, random administration of drugs, C1D1 as an example, as Figure 9 shown, when the doctor selects GCP, the plan item selection controls corresponding to each plan item of the visit plan will be output in the preset area ( Figure 10As shown, when the target plan item selection control selected by the doctor is the project informed consent reproduction process, the clinical research medical record template corresponding to the project informed consent reproduction process will be displayed in the medical record display area.

[0070] S1034. If the clinical diagnosis and treatment historical medical record is saved, in response to the selection operation on the diagnosis and treatment selection control, the clinical diagnosis and treatment historical medical record and the clinical diagnosis and treatment medical record template are output.

[0071] Among them, the clinical diagnosis and treatment historical medical record may include the initial diagnosis and treatment historical medical record and the follow-up diagnosis and treatment historical medical record.

[0072] Continue according to Figure 5 the example. As Figure 11 shown, when the doctor selects the initial diagnosis in the diagnosis and treatment selection control, if the initial diagnosis medical record is displayed in the preset display area ( Figure 11 the position below the initial diagnosis selection control in it), it indicates that the initial diagnosis and treatment historical medical record is saved in the database. When the doctor selects the initial diagnosis medical record control, the previously saved initial diagnosis historical medical record will be displayed in the medical record display area. As Figure 12 shown, when the doctor selects the follow-up diagnosis in the diagnosis and treatment selection control, if the medical records of each follow-up visit are displayed in the preset display area ( Figure 12 the position below the initial diagnosis selection control in it), it indicates that the follow-up diagnosis and treatment historical medical record has been saved in the database. When the doctor selects the medical record of the first follow-up visit, the previously saved medical record of the first follow-up visit will be displayed in the medical record display area. When the doctor selects the medical record of the second follow-up visit, the previously saved medical record of the second follow-up visit will be displayed in the medical record display area. When the doctor selects the third follow-up visit, the clinical diagnosis and treatment medical record template will be displayed in the medical record display area.

[0073] S1035. If the clinical research historical medical record is saved, in response to the selection operation on the clinical research selection control, the completed visit plan and the to-be-completed visit plan are output. The corresponding clinical research historical medical record is loaded under each completed plan item of the completed visit plan, and the clinical research medical record template is loaded under each uncompleted plan item of the to-be-completed visit plan.

[0074] If the clinical research historical medical record is saved in the database, it indicates that the current patient is not on the first visit. Continue according to Figure 5Taking the example of C1D1, the visit plan includes: the process of reproducing the informed consent of the project, the examinations during the screening period, confirmation of inclusion and exclusion, random administration of drugs. For example, when the doctor selects GCP, the completed visit plan item selection controls corresponding to each completed visit plan item of the completed visit plan and the to-be-completed visit plan item selection controls corresponding to each to-be-completed visit plan item of the to-be-completed visit plan will be output in the preset area. Optionally, the completed visit plan item selection controls and the to-be-completed visit plan item selection controls can be characterized by different colors, and the corresponding clinical research historical medical records will be loaded under the completed visit plan item, and the clinical research medical record template will be loaded under the to-be-completed visit plan item. When the doctor selects a certain completed visit plan item selection control, the clinical research historical medical record corresponding to the completed visit plan item corresponding to the selected completed visit plan item will be displayed in the medical record display area. When the doctor selects a certain to-be-completed visit plan item selection control, the clinical research medical record template will be displayed in the medical record display area.

[0075] In step S104, the current medical record information of the subject is received, the current medical record is obtained by filling the current medical record information into the corresponding template, and the current medical record is saved to the database.

[0076] After the doctor finishes registering the medical record, the clinical diagnosis and treatment electronic medical record system will save the current medical record in the database. By integrating the storage of clinical diagnosis and treatment medical records and clinical research medical records, the doctor can view both clinical diagnosis and treatment medical records and clinical research medical records through the database of the clinical diagnosis and treatment electronic medical record system. Compared with the prior art where clinical diagnosis and treatment medical records are stored in the clinical diagnosis and treatment electronic medical record system and clinical research medical records are stored in the clinical research project system, the problem of scattered storage and viewing of medical records can be effectively eliminated.

[0077] In one embodiment, in order for the doctor to clearly see which of the historical medical records of the subject saved in the database are clinical diagnosis and treatment historical medical records and which are clinical research historical medical records, when the current medical record is a clinical research medical record corresponding to the visit plan, a clinical research medical record identifier can be added to the clinical research medical record when saving the clinical research medical record to the database. Through this clinical research medical record identifier, it can be clearly seen which are clinical research historical medical records.

[0078] Among them, another scenario where a doctor logs in to the clinical diagnosis and treatment electronic medical record system using their own login account and password can be: during non-outpatient consultation periods, the doctor uses their own login account and password to log in to the clinical diagnosis and treatment electronic medical record system to view the clinical diagnosis and treatment historical medical records and clinical research historical medical records of the subjects in the clinical research projects they participated in. At this time, after obtaining the research information of the clinical research project that matches the role information from the clinical research project management system according to the role information of the doctor currently logged in to the system, all the historical medical records corresponding to all the subjects will be obtained from the database, and when displaying, it is not a general display, but for each subject's historical medical record obtained, it will be displayed in chronological order.

[0079] In the related art, the clinical diagnosis and treatment electronic medical record system is a software system used by doctors to record patients' medical records in clinical diagnosis and treatment; the operating object is the doctor, and the service object is the patient; the clinical research project management system is software used by research doctors to manage trial projects in clinical research; the operating object is the research doctor, and the service object is the subject; if one wants to view the clinical diagnosis and treatment historical medical records, they need to log in to the clinical diagnosis and treatment electronic medical record system, and if one wants to view the clinical research historical medical records, they need to log in to the clinical research project management system. The scattered storage of medical records makes it inconvenient to view. In the present disclosure, the clinical diagnosis and treatment historical medical records and clinical research historical medical records are stored in the database of the clinical diagnosis and treatment electronic medical record system at the same time. By only logging in to the clinical diagnosis and treatment electronic medical record system, one can view the clinical diagnosis and treatment historical medical records and clinical research historical medical records at the same time, and when displaying, it will be displayed in chronological order, so that doctors can comprehensively understand all the medical treatment situations and all the visit situations of the subjects in the hospital, making the medical records more readable and strengthening the reliability and scientific nature of the research conclusions.

[0080] Generally, when referring to the clinical diagnosis and treatment electronic medical record system, it is defaultly assumed to include the functions of doctors writing medical records and giving medical orders, that is, the functions that doctors use when patients go to the hospital for medical treatment. However, the clinical diagnosis and treatment electronic medical record system only includes clinical diagnosis and treatment medical records, that is, the medical record materials of patients' daily visits to the hospital, and does not include clinical research medical records. When the current patient is a subject in a clinical research project, the doctor needs to record the patient's clinical research medical records. At this time, the doctor needs to log in to the clinical research project management system and then record the clinical research medical records of the subject in the clinical research project management system. For doctors, they need to switch between two systems, which will make the doctor's operation more complex and waste the doctor's consultation time. In the present disclosure, doctors can complete the recording of both clinical diagnosis and treatment medical records and clinical research medical records in the clinical diagnosis and treatment electronic medical record system, saving the doctor's time and improving efficiency. In addition, in the related technologies, there is no unified template for recording clinical research medical records, and it is recorded based on the doctor's habits, which will make the recorded content less standardized and may also have problems of missing content. In the present disclosure, a clinical research medical record template is set, so that the recorded clinical research medical records can be more standardized, unified and complete, thus comprehensively ensuring the integrity and accuracy of the data of clinical research projects.

[0081] In one embodiment, a doctor can directly add a subject to his own clinical research project. Specifically, after obtaining the research information of the clinical research project that matches the role information from the clinical research project management system according to the role information of the doctor currently logged in to the system, the clinical diagnosis and treatment electronic medical record system can output the information of candidate patients and display an addition selection control for indicating whether to add the candidate patients to the clinical research project; in response to the selection operation on the addition selection control, the candidate patients are added to the clinical research project.

[0082] When a doctor adds a subject to his own clinical research project, the information of the candidate patients as shown in Table 1 can be displayed, and an addition selection control will be added after the information of each candidate patient. For the GCP addition control in Table 1, the doctor can select a suitable patient from the candidate patients and add him to the clinical research project. The identity of the candidate patients added to the clinical research project can be changed to subjects. For example, when the doctor wants to add the candidate patient numbered 3 to the clinical research project, the doctor directly clicks the GCP addition control in the information of the candidate patient numbered 3. The clinical diagnosis and treatment electronic medical record system responds to the selection operation on the GCP addition control of the candidate patient numbered 3 and adds the candidate patient numbered 3 to the clinical research project.

[0083] Table 1

[0084]

[0085] The above-mentioned candidate patients can be all the patients who registered on the day when the doctor makes a home visit. On the day when the doctor makes a home visit, a GCP control can be added to the information of all the registered patients. Or they can be all the historical patients who have visited the department where the doctor works. The doctor can retrieve the information of all the historical patients in his / her department and then add a GCP control to the information of each historical patient.

[0086] In one embodiment, after the historical medical records of each obtained subject are displayed in chronological order, the medical information management method of the present disclosure further includes the following steps A1 - A4:

[0087] A1. Receive a first modification instruction for the target historical medical record corresponding to any subject.

[0088] A2. Obtain the storage duration of the target historical medical record.

[0089] A3. When the storage duration is greater than the preset duration, output a prohibited modification prompt message.

[0090] A4. When the storage duration is less than or equal to the preset duration, modify the target historical medical record according to the first modification instruction and save the modified target historical medical record.

[0091] In the related art, the recording of clinical research medical records lacks timeliness constraints, which easily leads to the emergence of "retrospective" medical records. If the time since the visit is relatively long, doctors may forget some content, resulting in insufficient comprehensiveness and depth of the clinical research medical record content, and key information may be missed. Moreover, the clinical research medical record cannot immediately reflect the health status of the subject, and the timeliness and accuracy of the data are damaged. In the present disclosure, when modifying the target historical medical record, it is first necessary to determine the storage duration of the target historical medical record to be modified. Only when the storage duration is less than or equal to the preset duration can it be modified. If the stored target historical medical record exceeds the preset duration, the modification operation is not allowed; if it does not exceed the preset duration, the modification operation is allowed. For example, the above-mentioned modification operation can include: an editing operation or a deletion operation, that is, the first modification instruction instructs to perform an editing operation or a deletion operation.

[0092] Because clinical research has relatively high requirements for the timeliness of medical record writing to prevent the situation where research doctors write "memoirs" due to a long interval, that is, the content of the research medical record is inaccurate or has large errors, it is required that research doctors complete the writing of research medical records in a timely manner. In the present disclosure, by setting a time threshold of the preset duration, the time of institutional managers can be saved without having to check afterwards whether the research medical records are completed on time.

[0093] Taking the target historical medical record as an example of the target clinical research historical medical record, when editing or modifying the target clinical research historical medical record, it is first necessary to determine the storage duration of the target clinical research historical medical record. Only when the storage duration is less than or equal to the preset duration can editing or deletion operations be performed. If the saved target clinical research historical medical record exceeds the preset duration, editing or deletion operations are not allowed; if it does not exceed the preset duration, editing or deletion operations are allowed.

[0094] Since there is a large amount of content in the plan, doctors may make mistakes when inputting. To ensure the correctness of the visit plan, after logging in to the clinical diagnosis and treatment electronic medical record system, doctors will manually input the visit plan. After receiving the visit plan manually input by the doctor, the clinical diagnosis and treatment electronic medical record system will send the visit plan to the clinical research project management system for proofreading by the clinical research project management system. When the proofreading fails, the clinical research project management system sends a second modification instruction. After receiving the second modification instruction, the clinical diagnosis and treatment electronic medical record system displays the second modification instruction to let the doctor know that there is a problem with the current visit plan. Then the doctor modifies the visit plan and submits the modified visit plan to the clinical diagnosis and treatment electronic medical record system again. After receiving the modified visit plan, the clinical diagnosis and treatment electronic medical record system sends the modified visit plan to the clinical research project management system for proofreading again until a proofreading pass instruction is received; when the proofreading by the clinical research project management system passes, the clinical research project management system sends a proofreading pass instruction. After receiving the proofreading pass instruction, the clinical diagnosis and treatment electronic medical record system outputs the proofreading pass instruction, enabling the doctor to determine that the proofreading is completed through the proofreading pass instruction.

[0095] To save doctors' time and avoid them checking the visit plan item by item, the second modification instruction can indicate the specific location of the visit plan that needs to be modified.

[0096] In the present disclosure, for all editing, modification, saving, and deletion operations of research medical records, the modification track will be retained to ensure that every operation is traceable.

[0097] Based on the same inventive concept, the embodiment of the present application also provides a medical information management device for implementing the above-mentioned medical information management method. The implementation solution provided by this device to solve the problem is similar to the implementation solution described in the above method. Therefore, the specific limitations in one or more embodiments of the medical information management device provided below can refer to the limitations on the medical information management method in the above text and will not be repeated here.

[0098] In an exemplary embodiment, such as Figure 13As shown, a medical information management device is provided. The medical information management device is applied to a clinical diagnosis and treatment electronic medical record system. The medical information management device includes:

[0099] An acquisition module 11, configured to obtain research information of a clinical research project that matches the role information from a clinical research project management system according to the role information of the doctor currently logged in to the system. The research information includes: a visit plan and a clinical research medical record template;

[0100] A receiving module 12, configured to receive an identifier of the current patient, and display a clinical diagnosis and treatment selection control and a clinical research selection control when it is determined that the current patient is a subject according to the identifier of the current patient; wherein, the subject is a patient who has joined the clinical research project;

[0101] An output module 13, configured to output a corresponding clinical diagnosis and treatment medical record template in response to a selection operation on the diagnosis and treatment selection control; or, in response to a selection operation on the clinical research selection control, output the visit plan and load the clinical research medical record template under each plan item of the visit plan;

[0102] A saving module 14, configured to receive the current medical record information of the subject, fill the current medical record information into the corresponding medical record template to obtain the current medical record, and save the current medical record to a database.

[0103] As an optional implementation manner, the output module 13 is specifically configured to:

[0104] Detect whether the historical medical record of the subject is saved in the database; the historical medical record includes at least one of the following: a clinical diagnosis and treatment historical medical record and a clinical research historical medical record;

[0105] If the clinical diagnosis and treatment historical medical record is not saved, output a corresponding clinical diagnosis and treatment medical record template in response to a selection operation on the diagnosis and treatment selection control;

[0106] If the clinical research historical medical record is not saved, output a plan item selection control for each plan item of the visit plan in response to a selection operation on the clinical research selection control, and output a clinical research medical record template for the plan item corresponding to the target plan item selection control in response to a selection operation on the target plan item selection control;

[0107] If the clinical diagnosis and treatment historical medical record is saved, output the clinical diagnosis and treatment historical medical record and the clinical diagnosis and treatment medical record template in response to a selection operation on the diagnosis and treatment selection control;

[0108] If the clinical research historical medical records are saved, in response to the selection operation of the control for the clinical research, the completed visit plan and the to-be-completed visit plan are output. Under each completed plan item of the completed visit plan, the corresponding clinical research historical medical records are loaded, and under each uncompleted plan item of the to-be-completed visit plan, the clinical research medical record template is loaded.

[0109] As an optional implementation manner, the obtaining module 11 is specifically configured to:

[0110] Obtain the role information;

[0111] Send the role information to the clinical research project management system;

[0112] Receive the research information of the clinical research project that matches the role information sent by the clinical research project management system, where the research information of the clinical research project is sent by the clinical research project management system after detecting that it stores a clinical research project that matches the role information according to the role information.

[0113] As an optional implementation manner, the receiving module 12 is further configured to: receive the no-clinical-research-project prompt information sent by the clinical research project management system; the no-clinical-research-project prompt information is sent by the clinical research project management system after detecting that it does not store a clinical research project that matches the role information.

[0114] The output module 13 is further configured to: display the clinical diagnosis and treatment selection control.

[0115] As an optional implementation manner, the output module 13 is further configured to: when determining that the current patient is not the subject according to the identifier of the current patient, display the clinical diagnosis and treatment selection control.

[0116] As an optional implementation manner, after the obtaining module 11 obtains the research information of the clinical research project that matches the role information from the clinical research project management system according to the role information of the doctor currently logged in to the system, the output module 13 is further configured to output the information of the candidate patient and display the add selection control for whether to add the candidate patient to the clinical research project;

[0117] The receiving module 12 is further configured to: in response to the selection operation on the add selection control, add the candidate patient to the clinical research project.

[0118] As an optional implementation manner, the saving module 14 is further configured to: when the current medical record is the clinical research medical record corresponding to the visit plan, when saving the clinical research medical record to the database, add a clinical research medical record identifier to the clinical research medical record;

[0119] After the obtaining module 11 obtains the research information of the clinical research project that matches the role information from the clinical research project management system according to the role information of the doctor currently logged in to the system, the obtaining module 11 is further configured to: obtain the historical medical records corresponding to all subjects from the database;

[0120] The output module 13 is further configured to: display the historical medical records of each obtained subject in chronological order.

[0121] As an optional implementation manner, after the output module 13 displays the historical medical records of each obtained subject in chronological order, the receiving module 12 is further configured to: receive a first modification instruction for the target historical medical record corresponding to any subject;

[0122] The obtaining module 11 is further configured to: obtain the storage duration of the target historical medical record;

[0123] The output module 13 is further configured to: output a prohibited modification prompt message when the storage duration is greater than a preset duration;

[0124] The saving module 14 is further configured to: modify the target historical medical record according to the first modification instruction and save the modified target historical medical record when the storage duration is less than or equal to the preset duration.

[0125] As an optional implementation manner, it further includes a sending module. Before the obtaining module 11 obtains the research information of the clinical research project that matches the role information from the clinical research project management system according to the role information of the doctor currently logged in to the system, the receiving module 12 is further configured to: receive the visit plan input by the doctor;

[0126] The sending module is configured to send the visit plan to the clinical research project management system so that the clinical research project management system proofreads the visit plan. When the proofreading fails, the clinical research project management system sends a second modification instruction. When the proofreading passes, the clinical research project management system sends a proofreading passed instruction;

[0127] The receiving module 12 is further configured to: display the second modification instruction after receiving the second modification instruction, receive the modified visit plan, and send the modified visit plan to the clinical research project management system for proofreading again until the proofreading passed instruction is received;

[0128] The output module 13 is further configured to: output the proofreading passed instruction after receiving the proofreading passed instruction.

[0129] In an exemplary embodiment, a computer device is provided. The computer device can be a server or a terminal, and its internal structure diagram can be as shown in Figure 14 The computer device includes a processor, a memory, an input / output interface (Input / Output, abbreviated as I / O), and a communication interface. Among them, the processor, the memory, and the input / output interface are connected through a system bus, and the communication interface is connected to the system bus through the input / output interface. Among them, the processor of the computer device is used to provide computing and control capabilities. The memory of the computer device includes a non-volatile storage medium and an internal memory. The non-volatile storage medium stores an operating system, a computer program, and a database. The internal memory provides an environment for the operation of the operating system and the computer program in the non-volatile storage medium. The input / output interface of the computer device is used to exchange information between the processor and external devices. The communication interface of the computer device is used to communicate with an external terminal through a network connection. When the computer program is executed by the processor, it implements a medical information management method.

[0130] Those skilled in the art can understand that Figure 14 the structure shown in is only a block diagram of some structures related to the solution of the present application, and does not constitute a limitation on the computer device to which the solution of the present application is applied. The specific computer device may include more or fewer components than those shown in the figure, or combine certain components, or have different component arrangements.

[0131] In an exemplary embodiment, a computer device is further provided, including a memory and a processor. A computer program is stored in the memory, and when the processor executes the computer program, the steps in the above method embodiments are implemented.

[0132] In an exemplary embodiment, a computer-readable storage medium is provided, storing a computer program, and when the computer program is executed by the processor, the steps in the above method embodiments are implemented.

[0133] In an exemplary embodiment, a computer program product is provided, including a computer program, and when the computer program is executed by the processor, the steps in the above method embodiments are implemented.

[0134] It should be noted that the user information (including but not limited to user device information, user personal information, etc.) and data (including but not limited to data for analysis, stored data, displayed data, etc.) involved in the present application are all information and data authorized by the user or fully authorized by all parties, and the collection, use, and processing of relevant data need to comply with relevant regulations.

[0135] Those of ordinary skill in the art can understand that all or part of the processes in the methods of the above embodiments can be completed by instructing relevant hardware through a computer program. The computer program can be stored in a non-volatile computer-readable storage medium. When the computer program is executed, it can include the processes of the embodiments of the above methods. Among them, any reference to a memory, database, or other medium used in the embodiments provided in this application can include at least one of non-volatile and volatile memories. Non-volatile memories can include read-only memory (ROM), magnetic tapes, floppy disks, flash memories, optical memories, high-density embedded non-volatile memories, resistive random access memories (ReRAM), magnetoresistive random access memories (MRAM), ferroelectric random access memories (FRAM), phase change memories (PCM), graphene memories, etc. Volatile memories can include random access memory (RAM) or external cache memories, etc. By way of illustration and not limitation, RAM can be in various forms, such as static random access memory (SRAM) or dynamic random access memory (DRAM), etc.

[0136] The databases involved in the embodiments provided in this application can include at least one of relational databases and non-relational databases. Non-relational databases can include distributed databases based on blockchain, etc., without limitation. The processors involved in the embodiments provided in this application can be general-purpose processors, central processors, graphics processors, digital signal processors, programmable logics, data processing logics based on quantum computing, etc., without limitation.

[0137] The technical features of the above embodiments can be combined arbitrarily. For the sake of brevity of description, not all possible combinations of the technical features in the above embodiments are described. However, as long as there is no contradiction in the combination of these technical features, it should be considered as the scope described in this specification.

[0138] Specific examples are used in this article to elaborate on the principles and implementation manners of this application. The descriptions of the above embodiments are only used to help understand the method and its core idea of this application; at the same time, for those of ordinary skill in the art, according to the idea of this application, there will be changes in the specific implementation manners and application scopes. In summary, the content of this specification should not be construed as a limitation to this application.

Claims

1. A medical information management method, characterized in that: The medical information management method is applied to a clinical diagnosis and treatment electronic medical record system, and the medical information management method comprises: According to the role information of the doctor currently logged into the system, the research information of the clinical research project matching the role information is obtained from the clinical research project management system, wherein the research information includes: a visit plan and a clinical research medical record template; receiving an identifier of a current patient, and when determining that the current patient is a subject according to the identifier of the current patient, displaying a clinical diagnosis and treatment selection control and a clinical research selection control; wherein the subject is a patient who joins the clinical research project; In response to a selection operation on the diagnosis and treatment selection control, output a corresponding clinical diagnosis and treatment medical record template; or, in response to a selection operation on the clinical research selection control, output the visit plan and load the clinical research medical record template under each plan item of the visit plan; Receive the current medical record information of the subject, fill the current medical record information into the corresponding medical record template to obtain the current medical record, and save the current medical record to the database.

2. The medical information management method according to claim 1, characterized in that: In response to the selection operation on the diagnosis and treatment selection control, outputting the corresponding clinical diagnosis and treatment medical record template; or, in response to the selection operation on the clinical research selection control, outputting the visit plan, and loading the clinical research medical record template under each plan item of the visit plan, including: Detecting whether the subject's historical medical records are stored in the database; the historical medical records include at least one of the following: clinical diagnosis and treatment history records and clinical research history records; If the clinical diagnosis and treatment history medical record is not saved, in response to a selection operation on the diagnosis and treatment selection control, outputting a corresponding clinical diagnosis and treatment medical record template; If the clinical research history medical record is not saved, in response to a selection operation on the clinical research selection control, a plan item selection control for each plan item of the visit plan is output, and in response to a selection operation on a target plan item selection control, a clinical research medical record template for the plan item corresponding to the target plan item selection control is output; If the clinical diagnosis and treatment history medical record is saved, in response to a selection operation on the diagnosis and treatment selection control, the clinical diagnosis and treatment history medical record and the clinical diagnosis and treatment medical record template are output; If the historical medical records of clinical research are saved, in response to the selection operation of the clinical research selection control, the completed visit plan and the to-be-completed visit plan are output, and the corresponding historical medical record of clinical research is loaded under each completed plan item of the completed visit plan, and the clinical research medical record template is loaded under each unfinished plan item of the to-be-completed visit plan.

3. The medical information management method according to claim 1, characterized in that: The step of acquiring the research information of the clinical research project matching the role information of the doctor currently logged into the system from the clinical research project management system according to the role information of the doctor currently logged into the system comprises: Obtaining the role information; Sending the role information to the clinical research project management system; Receive research information of the clinical research project that matches the role information and is sent by the clinical research project management system, where the research information of the clinical research project is sent by the clinical research project management system after the clinical research project management system detects that it has stored the clinical research project that matches the role information based on the role information.

4. The medical information management method according to claim 3, characterized in that: The medical information management method further comprises: Receiving the prompt information of no clinical research project sent by the clinical research project management system; the prompt information of no clinical research project is sent after the clinical research project management system fails to detect that it has the clinical research project matching the role information stored in it; The clinical diagnosis and treatment selection control is displayed.

5. The medical information management method according to claim 1, characterized in that: The medical information management method further comprises: When it is determined that the current patient is not the subject according to the identifier of the current patient, the clinical diagnosis and treatment selection control is displayed.

6. The medical information management method according to claim 1, characterized in that: After acquiring the research information of the clinical research project matching the role information from the clinical research project management system according to the role information of the doctor currently logged into the system, the medical information management method further comprises: Output the information of candidate patients; An enrollment selection control showing whether to enroll the candidate patient in the clinical research project; In response to a selection operation on the enrollment selection control, the candidate patient is enrolled in the clinical research project.

7. The medical information management method according to claim 1, characterized in that: The medical information management method further comprises: When the current medical record is a clinical research medical record corresponding to the visit plan, when the clinical research medical record is saved in the database, a clinical research medical record identifier is added to the clinical research medical record; After acquiring the research information of the clinical research project matching the role information from the clinical research project management system according to the role information of the doctor currently logged into the system, the medical information management method further comprises: Obtaining historical medical records corresponding to all subjects from the database; The historical medical records of each subject obtained are displayed in chronological order.

8. The medical information management method according to claim 7, characterized in that: After displaying the acquired historical medical records of each subject in chronological order, the medical information management method further includes: receiving a first modification instruction for a target historical medical record corresponding to any subject; Obtaining the retention period of the target historical medical records; When the storage time is longer than the preset time, a prompt message prohibiting modification is output; When the preservation time is less than or equal to the preset time, the target historical medical record is modified according to the first modification instruction, and the modified target historical medical record is saved.

9. The medical information management method according to claim 1, characterized in that: Before acquiring the research information of the clinical research project matching the role information from the clinical research project management system according to the role information of the doctor currently logged into the system, the medical information management method further includes: receiving the visit plan input by the doctor; Sending the visit plan to the clinical research project management system so that the clinical research project management system can proofread the visit plan. If the proofreading fails, the clinical research project management system sends a second modification instruction. If the proofreading passes, the clinical research project management system sends a proofreading pass instruction. After receiving the second modification instruction, displaying the second modification instruction, receiving the modified visit plan, and sending the modified visit plan to the clinical research project management system for proofreading again until receiving the proofreading pass instruction; After receiving the proofreading passed instruction, the proofreading passed instruction is outputted.

10. A medical information management device, characterized in that: The medical information management device is applied to a clinical diagnosis and treatment electronic medical record system, and the medical information management device comprises: An acquisition module, used to acquire research information of clinical research projects matching the role information from the clinical research project management system according to the role information of the doctor currently logging into the system, wherein the research information includes: a visit plan and a clinical research medical record template; A receiving module, used for receiving an identification of a current patient, and when the current patient is determined as a subject according to the identification of the current patient, displaying a clinical diagnosis and treatment selection control and a clinical research selection control; wherein the subject is a patient who joins the clinical research project; An output module, configured to output a corresponding clinical diagnosis and treatment medical record template in response to a selection operation on the diagnosis and treatment selection control; or, in response to a selection operation on the clinical research selection control, output the visit plan and load the clinical research medical record template under each plan item of the visit plan; The saving module is used to receive the medical record information of the subject, fill the medical record information into the corresponding medical record template to obtain the medical record, and save the medical record to the database.

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