Hospital medical record data management system

Abstract

The invention belongs to the technical field of data management, and particularly relates to a hospital medical record data management system which comprises an electronic medical record module, a voice recognition processing module, an automatic template filling module, a data verification module, an integrated external equipment module, a remote input module, a patient self-service module and a data analysis feedback module. According to the method, errors and omissions caused by manual input can be remarkably reduced, the overall working efficiency and service level can be improved, the accuracy and reliability of data are enhanced, and solid support is provided for medical services.

Description

Technical Field

[0001] The present invention relates to the technical field of data management, and in particular to a hospital medical record data management system. Background Art

[0002] In clinical research, the most important first-hand data is the patient's medical records, which contain important information such as the patient's chief complaint, medical history, examination information, and doctor's orders. These medical records often come from the electronic medical record archives in the hospital archives. Clinical researchers retrieve medical records that meet the research goals from the electronic medical record archives based on research needs. However, the collected medical records are often scattered individual files, which cannot form a complete medical record archive system, making it difficult to organize and read medical records. Therefore, a medical record management system is needed to centrally manage these scattered data.

[0003] However, the existing management system still has the following technical problems when in use:

[0004] The current data management system is prone to errors or omissions when manually entering case data, and these errors may mislead subsequent treatment decisions, thereby affecting the patient's normal treatment.

[0005] Therefore, a hospital medical record management system is proposed to solve the above-mentioned problems. Summary of the Invention

[0006] The purpose of the present invention is to provide a hospital medical record management system to solve the problems raised in the above background technology.

[0007] To achieve the above-mentioned object, the present invention provides the following technical solutions: a hospital medical record management system, comprising an electronic medical record module, a voice recognition processing module, a template automatic filling module, a data verification module, an external device integration module, a remote input module, a patient self-service module, and a data analysis and feedback module;

[0008] The electronic medical record module provides a centralized platform for recording, storing and accessing patients' medical information;

[0009] The speech recognition processing module automatically converts the doctor's oral content into text and extracts structured data using NLP technology;

[0010] The template automatic filling module provides preset medical record templates according to different departments or disease types, and supports automatic filling of some fields;

[0011] The data verification module has built-in logic checking rules to verify the validity and consistency of input data in real time;

[0012] The integrated external device module is connected to the external hardware of laboratory instruments and imaging equipment to obtain test results and images directly from the equipment;

[0013] The remote input module supports medical staff to collect on-site data using tablet computers or smart phones;

[0014] The patient self-service module allows patients to update their personal information or upload relevant documents online;

[0015] The data analysis feedback module regularly performs quality assessments on medical record data, identifies common error patterns and generates improvement suggestions.

[0016] Preferably, the electronic medical record module includes a patient information management unit, a diagnosis and treatment record management unit, a medical order management unit, an examination report management unit, a nursing record management unit and a document management and signature unit;

[0017] The patient information management unit maintains the patient's basic personal information, such as name, gender, date of birth, and contact information; the medical record management unit records the specific content of each medical activity, including diagnosis results, treatment plan, and doctor's opinion; the medical order management unit records various medical orders issued by doctors, such as medication instructions, examination recommendations, and surgical arrangements; the examination report management unit collects and stores laboratory test results, imaging reports, and other examination data; the nursing record management unit records nurses' daily nursing activities for patients, such as vital signs monitoring, wound care, and drug administration; the document management and signature unit manages and stores various electronic documents, including informed consent forms and discharge summaries, and supports electronic signature functions.

[0018] Preferably, the speech recognition processing module includes a speech collection unit, a speech recognition unit, a speech processing unit and a template standardization processing unit;

[0019] The voice acquisition unit is responsible for capturing the user's voice input; the voice recognition unit converts the voice signal into text; the voice processing unit further analyzes and processes the recognized text; and the template standardization processing unit provides preset medical record templates according to different medical scenarios.

[0020] Preferably, the template automatic filling module includes a template design management unit, a field association unit and a data source integration unit;

[0021] The template design management unit is used to create, edit and manage various types of medical record templates; the field association unit is used to define how each field in the template corresponds to a specific data item in the database; the data source integration unit is used to connect and integrate information from different data sources, such as patient basic information, laboratory test results, and imaging reports.

[0022] Preferably, the data verification module includes a rule definition configuration unit, a field level verification unit, a correlation verification unit, and an external data source comparison unit;

[0023] The rule definition configuration unit is used to define and configure various data validation rules; the field-level validation unit is used to validate the data of a single field; the association validation unit is used to validate the logical relationship between multiple related fields; and the external data source comparison unit is used to compare the input data with the external data source.

[0024] Preferably, the integrated external device module includes a device interface management unit, a data acquisition and transmission unit, a data analysis and conversion unit, and a data storage and archiving unit;

[0025] The device interface management unit is used to manage and configure the connection interface with the external device; the data acquisition and transmission unit is used to collect data from the external device in real time and transmit it to the system; the data analysis and conversion unit is used to analyze the original data obtained from the external device and convert it into a format that can be recognized by the system; the data storage and archiving unit is used to securely store the verified data in the database and archive it on demand.

[0026] Preferably, the remote input module includes a mobile device management unit, a security authentication authority control unit, a data synchronization cache unit and a natural language processing unit;

[0027] The mobile device management unit is used to manage and configure various mobile devices that support remote input; the security authentication and permission control unit is used to authenticate remote users and assign appropriate permissions based on roles; the data synchronization cache unit is used to ensure that the data on the remote device is consistent with the main system; the natural language processing unit is used to support voice input and extract structured data through NLP technology.

[0028] Preferably, the patient self-service module includes a user registration and authentication unit, a personal information management unit, a health record query unit, and a medication reminder management unit;

[0029] The user registration and authentication unit is used to provide patient registration and identity verification functions; the personal information management unit is used to allow patients to view and update their basic information; the health record query unit is used to allow patients to view their electronic medical records, test reports, and imaging materials; the medication reminder management unit is used to provide medication reminder services and allow patients to record and manage the medications they are taking.

[0030] Preferably, the data analysis and feedback module includes a data acquisition and integration unit, a data cleaning and processing unit, and a report generation unit;

[0031] The data acquisition and integration unit collects and integrates data from various sources, ensuring that all relevant patient data are included in the analysis scope to form a comprehensive data set; the data cleaning and processing unit cleans and pre-processes the original data, removes noise and inconsistent data points, improves the quality of the data, and makes subsequent analysis more accurate and reliable; the report generation unit converts the analysis results into intuitive charts and reports, making complex analysis results easy to understand and facilitating medical staff and managers to quickly obtain key information.

[0032] Compared with the prior art, the present invention has the following beneficial effects:

[0033] This application, through the collaborative work of the electronic medical record module, voice recognition processing module, template automatic filling module, data verification and validation module, integrated external device module, remote input module, patient self-service module and data analysis and feedback module, can not only significantly reduce the errors and omissions caused by manual entry, but also improve the overall work efficiency and service level, not only enhance the accuracy and reliability of the data, but also provide solid support for medical services. BRIEF DESCRIPTION OF THE DRAWINGS

[0034] Figure 1 Module composition diagram of hospital medical record management system;

[0035] Figure 2 This is the unit composition diagram of the electronic medical record module;

[0036] Figure 3 This is a unit composition diagram of the speech recognition processing module;

[0037] Figure 4 Automatically fill in the module's unit composition diagram for the template;

[0038] Figure 5 This is a unit composition diagram of the data verification module;

[0039] Figure 6 It is a unit composition diagram for integrating external device modules;

[0040] Figure 7 This is the unit composition diagram of the remote input module;

[0041] Figure 8 This is the unit composition diagram of the patient self-service module;

[0042] Figure 9 This is a diagram of the unit composition of the data analysis feedback module. DETAILED DESCRIPTION

[0043] The following will clearly and completely describe the technical solutions in the embodiments of the present invention in conjunction with the accompanying drawings. Obviously, the described embodiments are only part of the embodiments of the present invention, not all of the embodiments. Based on the embodiments of the present invention, all other embodiments obtained by ordinary technicians in this field without making creative efforts are within the scope of protection of the present invention.

[0044] In the description of the present invention, it should be understood that the terms "upper", "lower", "front", "back", "left", "right", "top", "bottom", "inside", "outside", etc., indicating directions or positional relationships, are based on the directions or positional relationships shown in the accompanying drawings, and are only for the convenience of describing the present invention and simplifying the description, rather than indicating or implying that the device or element referred to must have a specific direction, be constructed and operated in a specific direction, and therefore should not be understood as limiting the present invention.

[0045] Example:

[0046] See also Figure 1-9 , the present invention provides a technical solution:

[0047] A hospital medical record management system, comprising an electronic medical record module, a voice recognition processing module, a template automatic filling module, a data verification module, an external device integration module, a remote input module, a patient self-service module, and a data analysis and feedback module;

[0048] The electronic medical record module provides a centralized platform for recording, storing and accessing patients' medical information;

[0049] The speech recognition processing module automatically converts the doctor's oral content into text and uses NLP technology (natural language processing technology) to extract structured data;

[0050] The template automatic filling module provides preset medical record templates according to different departments or disease types, and supports automatic filling of some fields;

[0051] The data verification module has built-in logic checking rules to verify the validity and consistency of input data in real time;

[0052] The integrated external device module is connected to the external hardware of laboratory instruments and imaging equipment to obtain test results and images directly from the equipment;

[0053] The remote input module supports medical staff to collect on-site data using tablet computers or smart phones;

[0054] The patient self-service module allows patients to update their personal information or upload relevant documents online;

[0055] The data analysis feedback module regularly performs quality assessments on medical record data, identifies common error patterns and generates improvement suggestions.

[0056] The electronic medical record module includes a patient information management unit, a diagnosis and treatment record management unit, a medical order management unit, an examination report management unit, a nursing record management unit and a document management and signature unit;

[0057] The Patient Information Management Unit, the foundation of the entire EMR, provides each patient with a unique identity, enabling all other units to organize and manage related medical information based on this identity. The Medical Record Management Unit leverages data provided by the Patient Information Management Unit to create and update each patient's medical history. It also interacts with the Medical Order Management Unit, the Laboratory Test Report Management Unit, and the Nursing Record Management Unit to ensure that all relevant information is integrated into a complete patient file.

[0058] The patient information management unit maintains the patient's basic personal information, such as name, gender, date of birth, and contact information; the medical record management unit records the specific content of each medical activity, including diagnosis results, treatment plan, and doctor's opinion; the medical order management unit records various medical orders issued by doctors, such as medication instructions, examination recommendations, and surgical arrangements; the examination report management unit collects and stores laboratory test results, imaging reports, and other examination data; the nursing record management unit records nurses' daily nursing activities for patients, such as vital signs monitoring, wound care, and drug administration; the document management and signature unit manages and stores various electronic documents, including informed consent forms and discharge summaries, and supports electronic signature functions.

[0059] The speech recognition processing module includes a speech acquisition unit, a speech recognition unit, a speech processing unit and a template standardization processing unit;

[0060] The voice acquisition unit first captures the user's voice input and then transmits the audio stream to the voice recognition engine unit for processing. This process requires high-quality audio input to ensure optimal recognition results. After receiving the audio data, the voice recognition unit uses its built-in algorithm to convert it into text format. The success rate of this step depends on the sophistication of the voice recognition technology and the quality of the training model. The voice processing unit conducts in-depth understanding and analysis, not only recognizing words but also understanding the meaning of sentences, thereby more accurately extracting relevant information.

[0061] The voice acquisition unit is responsible for capturing the user's voice input; the voice recognition unit converts the voice signal into text; the voice processing unit further analyzes and processes the recognized text; and the template standardization processing unit provides preset medical record templates according to different medical scenarios.

[0062] The template automatic filling module includes a template design management unit, a field association unit and a data source integration unit;

[0063] The template design management unit is used to create, edit and manage various types of medical record templates; the field association unit is used to define how each field in the template corresponds to a specific data item in the database; the data source integration unit is used to connect and integrate information from different data sources, such as patient basic information, laboratory test results, and imaging reports.

[0064] The data verification module includes a rule definition configuration unit, a field level verification unit, a correlation verification unit, and an external data source comparison unit;

[0065] The rule definition configuration unit is used to define and configure various data validation rules; the field-level validation unit is used to validate the data of a single field; the association validation unit is used to validate the logical relationship between multiple related fields; and the external data source comparison unit is used to compare the input data with the external data source.

[0066] The integrated external device module includes a device interface management unit, a data acquisition and transmission unit, a data analysis and conversion unit, and a data storage and archiving unit;

[0067] The device interface management unit is used to manage and configure the connection interface with the external device; the data acquisition and transmission unit is used to collect data from the external device in real time and transmit it to the system; the data analysis and conversion unit is used to analyze the original data obtained from the external device and convert it into a format that can be recognized by the system; the data storage and archiving unit is used to securely store the verified data in the database and archive it on demand.

[0068] The remote input module includes a mobile device management unit, a security authentication authority control unit, a data synchronization cache unit and a natural language processing unit;

[0069] The mobile device management unit is used to manage and configure various mobile devices that support remote input; the security authentication and permission control unit is used to authenticate remote users and assign appropriate permissions based on roles; the data synchronization cache unit is used to ensure that the data on the remote device is consistent with the main system; the natural language processing unit is used to support voice input and extract structured data through NLP technology.

[0070] The patient self-service module includes a user registration and authentication unit, a personal information management unit, a health record query unit, and a medication reminder management unit;

[0071] The user registration and authentication unit is used to provide patient registration and identity verification functions; the personal information management unit is used to allow patients to view and update their basic information; the health record query unit is used to allow patients to view their electronic medical records, test reports, and imaging materials; the medication reminder management unit is used to provide medication reminder services and allow patients to record and manage the medications they are taking.

[0072] The data analysis and feedback module includes a data acquisition and integration unit, a data cleaning and processing unit, and a report generation unit;

[0073] The data acquisition and integration unit collects and integrates data from various sources, ensuring that all relevant patient data are included in the analysis scope to form a comprehensive data set; the data cleaning and processing unit cleans and pre-processes the original data, removes noise and inconsistent data points, improves the quality of the data, and makes subsequent analysis more accurate and reliable; the report generation unit converts the analysis results into intuitive charts and reports, making complex analysis results easy to understand and facilitating medical staff and managers to quickly obtain key information.

[0074] The above shows and describes the basic principles and main features of the present invention and the advantages of the present invention. For those skilled in the art, it is obvious that the present invention is not limited to the details of the above exemplary embodiments, and the present invention can be implemented in other specific forms without departing from the spirit or basic characteristics of the present invention; therefore, no matter from which point of view, the embodiments should be regarded as exemplary and non-restrictive. The scope of the present invention is limited by the appended claims rather than the above description. Therefore, it is intended that all changes that fall within the meaning and scope of the equivalent elements of the claims are included in the present invention, and any figure signs in the claims should not be regarded as limiting the claims involved.

[0075] While embodiments of the present invention have been shown and described, it will be appreciated by those skilled in the art that various changes, modifications, substitutions, and variations may be made to these embodiments without departing from the principles and spirit of the invention, and that the scope of the invention is defined by the appended claims and their equivalents.

Claims

1. A hospital medical record management system, characterized in that: It includes electronic medical record module, voice recognition processing module, template automatic filling module, data verification and validation module, external device integration module, remote input module, patient self-service module and data analysis and feedback module; The electronic medical record module provides a centralized platform for recording, storing and accessing patients' medical information; The speech recognition processing module automatically converts the doctor's oral content into text and uses NLP technology to extract structured data; The template automatic filling module provides preset medical record templates according to different departments or disease types, and supports automatic filling of some fields; The data verification module has built-in logic checking rules to verify the validity and consistency of input data in real time; The integrated external device module is connected to the external hardware of laboratory instruments and imaging equipment to obtain test results and images directly from the equipment; The remote input module supports medical staff to collect on-site data using tablet computers or smart phones; The patient self-service module allows patients to update their personal information or upload relevant documents online; The data analysis feedback module regularly performs quality assessments on medical record data, identifies common error patterns and generates improvement suggestions.

2. A hospital medical record management system according to claim 1, characterized in that: The electronic medical record module includes a patient information management unit, a diagnosis and treatment record management unit, a medical order management unit, an examination report management unit, a nursing record management unit and a document management and signature unit; The patient information management unit maintains the patient's basic personal information, such as name, gender, date of birth, and contact information; the medical record management unit records the specific content of each medical activity, including diagnosis results, treatment plan, and doctor's opinion; the medical order management unit records various medical orders issued by doctors, such as medication instructions, examination recommendations, and surgical arrangements; the examination report management unit collects and stores laboratory test results, imaging reports, and other examination data; the nursing record management unit records nurses' daily nursing activities for patients, such as vital signs monitoring, wound care, and drug administration; the document management and signature unit manages and stores various electronic documents, including informed consent forms and discharge summaries, and supports electronic signature functions.

3. A hospital medical record management system according to claim 1, characterized in that: The speech recognition processing module includes a speech acquisition unit, a speech recognition unit, a speech processing unit and a template standardization processing unit; The voice acquisition unit is responsible for capturing the user's voice input; the voice recognition unit converts the voice signal into text; the voice processing unit further analyzes and processes the recognized text; and the template standardization processing unit provides preset medical record templates according to different medical scenarios.

4. A hospital medical record management system according to claim 1, characterized in that: The template automatic filling module includes a template design management unit, a field association unit and a data source integration unit; The template design management unit is used to create, edit and manage various types of medical record templates; The field association unit is used to define how each field in the template corresponds to a specific data item in the database; the data source integration unit is used to connect and integrate information from different data sources, such as basic patient information, laboratory test results, and imaging reports.

5. A hospital medical record management system according to claim 1, characterized in that: The data verification module includes a rule definition configuration unit, a field level verification unit, a correlation verification unit, and an external data source comparison unit; The rule definition configuration unit is used to define and configure various data validation rules; the field-level validation unit is used to validate the data of a single field; the association validation unit is used to validate the logical relationship between multiple related fields; and the external data source comparison unit is used to compare the input data with the external data source.

6. A hospital medical record management system according to claim 1, characterized in that: The integrated external device module includes a device interface management unit, a data acquisition and transmission unit, a data analysis and conversion unit, and a data storage and archiving unit; The device interface management unit is used to manage and configure the connection interface with the external device; the data acquisition and transmission unit is used to collect data from the external device in real time and transmit it to the system; the data analysis and conversion unit is used to analyze the original data obtained from the external device and convert it into a format that can be recognized by the system; the data storage and archiving unit is used to securely store the verified data in the database and archive it on demand.

7. A hospital medical record management system according to claim 1, characterized in that: The remote input module includes a mobile device management unit, a security authentication authority control unit, a data synchronization cache unit and a natural language processing unit; The mobile device management unit is used to manage and configure various mobile devices that support remote input; the security authentication and permission control unit is used to authenticate remote users and assign appropriate permissions based on roles; the data synchronization cache unit is used to ensure that the data on the remote device is consistent with the main system; the natural language processing unit is used to support voice input and extract structured data through NLP technology.

8. A hospital medical record management system according to claim 1, characterized in that: The patient self-service module includes a user registration and authentication unit, a personal information management unit, a health record query unit, and a medication reminder management unit; The user registration and authentication unit is used to provide patient registration and identity verification functions; the personal information management unit is used to allow patients to view and update their basic information; the health record query unit is used to allow patients to view their electronic medical records, test reports, and imaging materials; the medication reminder management unit is used to provide medication reminder services and allow patients to record and manage the medications they are taking.

9. A hospital medical record management system according to claim 1, characterized in that: The data analysis and feedback module includes a data acquisition and integration unit, a data cleaning and processing unit, and a report generation unit; The data acquisition and integration unit collects and integrates data from various sources, ensuring that all relevant patient data are included in the analysis scope to form a comprehensive data set; the data cleaning and processing unit cleans and pre-processes the original data, removes noise and inconsistent data points, improves the quality of the data, and makes subsequent analysis more accurate and reliable; the report generation unit converts the analysis results into intuitive charts and reports, making complex analysis results easy to understand and facilitating medical staff and managers to quickly obtain key information.

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