Method and device for comparing content differences of different paragraphs of electronic medical record

Abstract

The invention relates to a method and a device for comparing content differences of different paragraphs of an electronic medical record. The marking module is used for marking modified contents before and after modification of a certain section of contents of different electronic medical records or the same electronic medical record. In order to achieve the purpose, the invention provides a method and device for marking the modified content in the electronic medical record, and belongs to the technical field of data processing. The method comprises the following steps: collecting electronic medical record data from a database or a memory, calculating the content of the electronic medical record through an algorithm, calculating the content of the same electronic medical record before and after modification, and marking the part subjected to content modification so as to more quickly check the modified content and the position of the modified content. Therefore, whether the electronic case is modified or not is judged, and whether the electronic case is repeated with other patient cases or not is judged. The electronic case quality can be improved during electronic case quality control.

Description

TECHNICAL FIELD

[0001] The present application relates to a method and device for comparing the content differences of different paragraphs of an electronic medical record. BACKGROUND

[0002] In a medical information system, an electronic medical record is a core data carrier for recording the diagnosis and treatment process of a patient. Its accuracy and consistency are crucial. However, in actual medical practice, due to differences in doctors' writing habits, medical record version updates, transcriptions or modifications, etc., two medical records of different patients may have repeated content, or the same medical record may have differences after multiple adjustments. This repetition or modification phenomenon may have a negative impact on medical record quality management, medical insurance audit, scientific research data cleaning, etc. Therefore, a technical solution is needed to accurately determine the repetition of the content of two medical records to improve the consistency and reliability of the data.

[0003] In practical applications, the repetition or modification of medical record content can take many forms, such as slight changes in wording, addition or deletion of part of the content, structural adjustment, or even similar expressions in semantics. For example, a doctor may use different words to describe the same illness when recording twice, or add or adjust part of the content based on the original medical record. Traditional character matching methods cannot effectively identify these complex situations, so more intelligent text comparison techniques are needed, combined with text similarity calculation and medical knowledge base, to deeply analyze the semantic and structural differences of medical record text, and accurately determine the degree of repetition. In this way, not only can the storage and management of medical records be optimized to reduce redundant data, but also the utilization value of medical record data can be improved to support medical quality control, reasonable charge audit, and data governance for clinical research.

[0004] In addition, medical records are important evidence in the medical process and play a key role in determining whether there is a mistake in the diagnosis and treatment process. However, due to the possibility of tampering with electronic medical records, their authenticity is often questioned. If the modification of electronic medical records is not standardized, it may lead to or exacerbate medical disputes. Therefore, ensuring the authenticity and integrity of electronic medical records is not only a technical issue, but also an important part of medical quality management. SUMMARY

[0005] The present application relates to a method and device for comparing the content differences of different paragraphs of an electronic medical record. It is used to check whether the content of the same medical record or different medical records is repeated.

[0006] To achieve the above object, the present application provides a method and device for marking modified content in electronic medical records, belonging to the technical field of data processing. The method comprises: collecting electronic medical record data from a database or a memory, calculating the content of the electronic medical record by an algorithm and calculating the content before and after modification for the same electronic medical record, marking the part of the content that is modified, so as to quickly view the modified content and the location of the modified content.

[0007] As a further optimization, the collection of electronic medical record data can be transmitted through an interface, copied by a mobile storage device, or transmitted by a database.

[0008] As a further optimization, the collected electronic medical record data includes structured and unstructured data content.

[0009] As a further optimization, the collected electronic medical record data can be converted from a paper file to an electronic file by computer recognition.

[0010] As a further optimization, the same effect can be achieved during the generation of the electronic medical record, and the identification of the modified content does not have to wait for the entire electronic medical record to be generated.

[0011] As a further optimization, the problem location can be marked and displayed in various forms such as different colors, different display methods, lists, printing, and automatically generated electronic documents.

[0012] The embodiments of the present application have the following advantages:

[0013] 1. Improve the efficiency of auditing: by only auditing the modified content, the tedious process of re-auditing the entire electronic medical record is avoided, greatly saving the time and effort of the auditors and improving the work efficiency.

[0014] 2. Ensure the accuracy of the audit: accurately positioning the modified content of the electronic medical record helps the auditors quickly determine whether the modification meets the requirements, reduces omissions and misjudgments, and improves the reliability and consistency of the quality of medical records.

[0015] 3. Reduce the cost of artificial quality control: reduce the workload of the auditors on the entire medical record, effectively reduce the time cost and human resource investment of artificial auditing, and optimize the quality control workflow.

[0016] 4. Optimize resource allocation: through the automatic and refined modification positioning and auditing mechanism, the auditors are freed from repetitive work, so that they can concentrate their efforts on more complex or critical issues, improving the utilization efficiency of the overall medical resources. BRIEF DESCRIPTION OF DRAWINGS

[0018] Figure 1For flowchart. DETAILED DESCRIPTION

[0020] Modify the content marking process, see Figure 1 , including the following steps:

[0021] S1, the electronic medical record system of the hospital provides electronic medical records, supports interface transmission, memory copy, database reading, manual input and other ways to provide data content;

[0022] S2, complete data collection and provide data content to S3 and make preliminary data processing, such as removing invalid data, blank data, and unified data format;

[0023] S3, select N copies of electronic medical records that need to be compared, which can be multiple versions of the same electronic medical record before and after modification or different electronic medical records of different patients;

[0024] S4, configure a medical knowledge base, which has the ability to identify electronic medical record content. Electronic medical record content refers to the actual situation of the patient. Due to different personal habits and other reasons, the actual situation will be described in different ways, but the actual medical situation is only one;

[0025] S5, mark the content of the electronic medical record through the medical knowledge base. For different description methods, unify the description method to facilitate the judgment of whether there is repeated content. The calculation process is to select the content in the electronic medical record, and then mark the label according to the standard description method marked in the knowledge base according to the actual situation of the patient expressed by the content through the medical knowledge base. The same label content is identified as content duplication;

[0026] S6, check if the marked content has repeated content, and count the consistency rate of the original text. Mark the same content part calculated by label or location information, change the color, etc. Different text format from the original text.

Claims

1. The present application provides an electronic medical record different paragraph content difference comparison method and device, belonging to the technical field of data processing. The method comprises: 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 different electronic medical records or a certain segment of the same electronic medical record is calculated. Meanwhile, the algorithm is combined with 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 electronic medical record is compared, and the modified part is found out.

3. The method of claim 1, wherein Different paragraphs of different electronic medical records or different paragraphs of the same electronic medical record are compared.

4. The algorithm of claim 1, wherein, The algorithm is a computer program or a computer program stored in a computing device.

5. The location of claim 1, wherein, The electronic medical record modifies the content, and the modified content is the modification of what content of the electronic medical record before modification.

6. The knowledge base of claim 1 contains medical content, setting rules, text logic and format, which are manually confirmed and maintained data.

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