Method and device for marking modified content in electronic medical record
By accurately locating and marking modifications in electronic medical records, the problem of difficulty in identifying modifications in existing technologies has been solved, enabling an efficient and accurate review process and improving the data quality and resource allocation of electronic medical records.
Patent Information
- Application Number
- CN202510299131.2
- Authority / Receiving Office
- CN · China
- Patent Type
- Applications(China)
- Current Assignee / Owner
- Filing Date
- 2025-03-13
- Publication Date
- 2025-12-05
AI Technical Summary
When modifying content in electronic medical records, existing technology makes it difficult to accurately locate the modification location and content, causing reviewers to have to re-examine the entire medical record, which consumes a lot of time and energy, and the modification may lead to misjudgment or omission.
By collecting electronic medical record data, algorithms are used to calculate the differences in content before and after modification, and the modified locations and content are marked using different colors, display methods, lists, etc., to achieve precise location and marking.
This improved the efficiency and accuracy of the review process, reduced the time and labor costs associated with repeated reviews, and ensured the data quality and consistency of medical records.
Smart Images
Figure CN121072467A_ABST
Abstract
Description
Technical Field
[0001] This invention relates to a method and apparatus for marking modifications in electronic medical records. Background Technology
[0002] Most medical institutions have now completed their informatization and electronic transformation, during which medical records have been converted from paper-based to electronic data. With the continuous development of medical informatization, electronic medical record data is constantly expanding, covering increasingly comprehensive content. To ensure the quality of electronic medical records, they need to be reviewed by auditors after completion. If any content in the electronic medical record does not meet the requirements, it needs to be modified by the writer. However, often due to the large amount of data in electronic medical records, and the possibility of changes or deletions after modifications, auditors cannot accurately locate the modified content during re-review, nor can they verify whether the modifications meet the requirements. Auditors often have to re-review the entire electronic medical record, consuming considerable time and effort. If only the modified content could be precisely located and reviewed, the workload of auditors could be greatly reduced.
[0003] Furthermore, because modifications to electronic medical records are not simply deletions or corrections, but rather revisions to medical descriptions—modifications of the meaning expressed in the text—it's common for the same content to be presented in different ways. Therefore, identifying and resolving modifications to medical content in electronic medical records presents a significant challenge.
[0004] This invention can improve the accuracy of auditing, prevent omissions, ensure the comparison of medical records, improve the data quality of electronic medical records, significantly reduce the cost of manual quality control, improve work efficiency, and optimize resource allocation. Summary of the Invention
[0005] This invention relates to a method and apparatus for marking modifications in electronic medical records. It is used to mark and display the modifications made to the same electronic medical record before and after the modification.
[0006] To achieve the above objectives, this invention provides a method and apparatus for marking modified content in electronic medical records, belonging to the field of data processing technology. The method includes: collecting electronic medical record data from a database or storage device; calculating the electronic medical record content using an algorithm, performing calculations on the content before and after modification of the same electronic medical record; and marking the modified portions of the content to facilitate faster viewing of the modified content and its location.
[0007] As a further optimization, the collected electronic medical record data can be transmitted via interface, copied to mobile storage devices, or transmitted to a database.
[0008] As a further optimization, the collected electronic medical record data includes both structured and unstructured data.
[0009] As a further optimization, the collected electronic medical record data can be converted from paper documents into electronic documents through computer recognition.
[0010] As a further optimization, it can play the same role in the electronic medical record generation process, instead of having to wait until the entire electronic medical record is generated before the content of the modification can be identified.
[0011] As a further optimization, the marked problem locations can be displayed in various forms such as different colors, different display methods, lists, printing, and automatically generating electronic documents.
[0012] The embodiments of the present invention have the following advantages:
[0013] Improve review efficiency: By reviewing only the modified content, the tedious process of reviewing the entire electronic medical record is avoided, which greatly saves the reviewers' time and energy and improves work efficiency.
[0014] Improving the accuracy of review: Accurately locating the modification location and content of electronic medical records helps reviewers quickly determine whether they meet the requirements, reducing omissions and misjudgments, and improving the reliability and consistency of medical record data quality. Attached Figure Description
[0015] Figure 1 A flowchart illustrating the process of modifying content tags.
[0016] Figure 2 This is a schematic diagram of the algorithm process.
[0017] For details on modifying the content tagging process, please refer to [link / reference]. Figure 1 This includes the following steps:
[0018] S1. The hospital's electronic medical record system provides electronic medical records and supports data content delivery through methods such as interface transmission, memory copying, database reading, and manual entry.
[0019] S2. Complete data collection by organizing the data provided in S3 and performing preliminary data processing, such as removing invalid and blank data, and standardizing the data format.
[0020] S3. Save the electronic medical record before and after modification as two separate files for easy comparison later.
[0021] S4. The electronic medical record data is processed through the built-in algorithm to obtain the location information of the modified content;
[0022] S5. Mark the content of the electronic medical record before and after modification using location information.
[0023] Example 2: Procedure, see [link / reference] Figure 2 This includes the following steps:
[0024] S1. Divide the content into multiple groups using punctuation marks as reference points. Compare the content groups to see if the content is consistent. Items with consistent content are considered unchanged; items with inconsistent content are also considered unchanged.
[0025] S2. All content groups are assigned a fixed number as location information;
[0026] The knowledge base contains medical knowledge, drug knowledge, surgical knowledge, disease knowledge, examination knowledge, and laboratory knowledge, etc., and is labeled according to the content in the content group. This knowledge base is maintained manually by personnel with medical knowledge. The maintenance method involves inputting medical knowledge to form a dataset for easy system recognition and use. Knowledge content consists of two parts: number and tag. Different knowledge content with correlations has their numbers combined into a dataset. When a content group contains a knowledge base tag, it is assumed that the content group corresponds to the knowledge base content, and the number is bound accordingly. This method is used to mark unmodified content.
[0027] The modified content is marked based on the S3 knowledge base;
[0028] The content was modified based on the knowledge base tags of S3;
[0029] To calculate relevance, content that has been modified and content that has been modified have the same or opposite tags on the knowledge base tags and are considered to be related.
[0030] Mark related content to identify the modified content. Marking can be done by changing content color, text style, setting tags, extracting information, or using arrow indicators;
[0031] Although the present invention has been described in detail above with general descriptions and specific embodiments, modifications or improvements can be made to it, which will be obvious to those skilled in the art. Therefore, all such modifications or improvements made without departing from the spirit of the present invention fall within the scope of protection claimed by the present invention.
Claims
1. The application provides a method and device for marking modified content in an electronic medical record, and belongs to the technical field of data processing. The method comprises the following steps: The electronic medical record data is collected from a database or memory, the electronic medical record content is calculated by an algorithm, and the content before and after modification of the same electronic medical record is calculated. The algorithm combines a knowledge base, and the part of the content that is modified is marked by the algorithm, so that the modified content and the location of the modified content can be viewed more quickly.
2. The content tag of claim 1, wherein, The content before and after modification of the same medical record is compared, and the modified part is found out.
3. The algorithm of claim 1, wherein, The algorithm is a computer program or a computer program stored in a computing device.
4. The location of claim 1, wherein, The electronic medical record is modified, and the modified content is the modification of what content of the electronic medical record before modification.
5. The medical content, setting rules, text logic and format of claim 1 are manually confirmed content.