CN111524569A - Electronic medical record diagnosis and maintenance system - Google Patents

Abstract

The invention relates to the technical field of electronic medical records, in particular to an electronic medical record diagnosis maintenance system which comprises diagnosis selection and differential diagnosis, wherein the diagnosis selection is used for selecting diagnosis names, the diagnosis names are based on national standard diagnosis codes, the differential diagnosis is used for identifying current disease diagnosis and other diseases and eliminating the possibility of other diseases, the differential diagnosis comprises a differential diagnosis candidate level, a diagnosis plan, an authorized department and configuration differential diagnosis, the diagnosis plan is used for confirming or denying the diagnosis selection, the authorized department is used for selecting the name of a hospital belonging to the department level, and the configuration differential diagnosis is used for associating and displaying all the disease names suitable for the diagnosis names. The electronic medical record diagnosis and maintenance system has higher operability and flexible editing capacity, reduces the probability of misdiagnosis and misdiagnosis, reduces the workload of medical staff for writing medical records, and improves the working efficiency.

Description

Translated fromChinese

一种电子病历诊断维护系统An electronic medical record diagnosis and maintenance system

技术领域technical field

本发明涉及电子病历技术领域，具体为一种电子病历诊断维护系统。The invention relates to the technical field of electronic medical records, in particular to an electronic medical record diagnosis and maintenance system.

背景技术Background technique

电子病历系统，是医学专用软件。医院通过电子病历以电子化方式记录患者就诊的信息，包括：首页、病程记录、检查检验结果、医嘱、手术记录、护理记录等等，其中既有结构化信息，也有非结构化的自由文本，还有图形图象信息。涉及病人信息的采集、存储、传输、质量控制、统计和利用。The electronic medical record system is a special software for medicine. Hospitals electronically record the information of patients' visits through electronic medical records, including: home page, disease course records, inspection and test results, doctor's orders, surgical records, nursing records, etc., which include both structured information and unstructured free texts. There is also graphic image information. It involves the collection, storage, transmission, quality control, statistics and utilization of patient information.

目前，现有的电子病历在使用时，病历诊断的可操作性和灵活性交底，导致病历书写错误的状况下极难被医护人员察觉，且许多诊断内容需要医护人员重复填写，增加书写的工作量，降低工作效率。鉴于此，我们提出一种电子病历诊断维护系统。At present, when the existing electronic medical records are used, the operability and flexibility of the diagnosis of the medical records are disclosed, which makes it extremely difficult for the medical staff to detect the wrong writing of the medical records, and many diagnostic contents need to be filled in by the medical staff repeatedly, which increases the work of writing. volume and reduce work efficiency. In view of this, we propose an electronic medical record diagnosis and maintenance system.

发明内容SUMMARY OF THE INVENTION

本发明的目的在于提供一种电子病历诊断维护系统，以解决上述背景技术中提出的问题。The purpose of the present invention is to provide an electronic medical record diagnosis and maintenance system to solve the problems raised in the above background art.

为实现上述目的，本发明提供如下技术方案：To achieve the above object, the present invention provides the following technical solutions:

一种电子病历诊断维护系统，所述系统包括：An electronic medical record diagnosis and maintenance system, the system includes:

诊断选择，所述诊断选择用于选择诊断名称，所述诊断名称基于国家标准规范诊断编码；Diagnosis selection, the diagnosis selection is used to select a diagnosis name, and the diagnosis name is based on the national standard standard diagnosis code;

鉴别诊断，所述鉴别诊断用于将当前诊断名称与其他疾病进行鉴别，并排除其他疾病的可能性，且所述鉴别诊断包括鉴别诊断待选级别、拟诊诊断、授权科室和配置鉴别诊断。Differential diagnosis, the differential diagnosis is used to distinguish the current diagnosis name from other diseases and exclude the possibility of other diseases, and the differential diagnosis includes the differential diagnosis candidate level, the proposed diagnosis, the authorized department and the configuration differential diagnosis.

优选的，所述诊断选择还包括新增诊断，所述新增诊断按统一格式定义诊断编码。Preferably, the diagnosis selection further includes a newly added diagnosis, and the newly added diagnosis defines a diagnosis code in a unified format.

优选的，所述鉴别诊断待选级别包括全院级别和科室级别；Preferably, the differential diagnosis candidate levels include hospital level and department level;

所述拟诊诊断用于设置当前诊断名称是否为拟诊诊断；The proposed diagnosis is used to set whether the current diagnosis name is the proposed diagnosis;

所述授权科室用于将当前诊断名称授权给至少一个科室；The authorized department is used to authorize the current diagnosis name to at least one department;

所述配置鉴别诊断用于关联和显示所有适用于所述诊断名称的疾病名称。The configured differential diagnosis is used to correlate and display all disease names that apply to the diagnosis name.

优选的，所述科室级别可选择一个或多个科室。Preferably, one or more departments can be selected for the department level.

优选的，所述诊断名称关联生成的多个疾病名称可以编辑诊断描述或删除。Preferably, the multiple disease names generated by the association of the diagnosis names can be edited or deleted.

与现有技术相比，本发明的有益效果是：Compared with the prior art, the beneficial effects of the present invention are:

1.该电子病历诊断维护系统，具有较高的可操作性和灵活的编辑能力，降低误诊错诊的概率。1. The electronic medical record diagnosis and maintenance system has high operability and flexible editing ability, reducing the probability of misdiagnosis and misdiagnosis.

2.该电子病历诊断维护系统，诊断名称与疾病名称进行关联，减少医护人员的书写病历的工作量，提高工作效率。2. In the electronic medical record diagnosis and maintenance system, the diagnosis name is associated with the disease name, which reduces the workload of medical personnel for writing medical records and improves work efficiency.

附图说明Description of drawings

图1为本发明的整体结构示意图；Fig. 1 is the overall structure schematic diagram of the present invention;

图2为本发明的操作流程图。FIG. 2 is a flow chart of the operation of the present invention.

具体实施方式Detailed ways

下面将结合本发明实施例中的附图，对本发明实施例中的技术方案进行清楚、完整地描述，显然，所描述的实施例仅仅是本发明一部分实施例，而不是全部的实施例。基于本发明中的实施例，本领域普通技术人员在没有做出创造性劳动前提下所获得的所有其他实施例，都属于本发明保护的范围。The technical solutions in the embodiments of the present invention will be clearly and completely described below with reference to the accompanying drawings in the embodiments of the present invention. Obviously, the described embodiments are only a part of the embodiments of the present invention, but not all of the embodiments. Based on the embodiments of the present invention, all other embodiments obtained by those of ordinary skill in the art without creative efforts shall fall within the protection scope of the present invention.

一种电子病历诊断维护系统，如图1所示，系统包括诊断选择和鉴别诊断，诊断选择用于选择诊断名称，诊断名称基于国家标准规范诊断编码，鉴别诊断用于将当前诊断名称与其他疾病进行鉴别，并排除其他疾病的可能性，且鉴别诊断包括鉴别诊断待选级别、拟诊诊断、授权科室和配置鉴别诊断。An electronic medical record diagnosis and maintenance system, as shown in Figure 1, the system includes diagnosis selection and differential diagnosis, diagnosis selection is used to select the diagnosis name, the diagnosis name is based on the national standard standard diagnosis code, and the differential diagnosis is used to compare the current diagnosis name with other diseases. Identify and exclude the possibility of other diseases, and the differential diagnosis includes the candidate level of the differential diagnosis, the proposed diagnosis, the authorized department and the configuration of the differential diagnosis.

本实施例中，诊断选择还包括新增诊断，新增诊断按统一格式定义诊断编码，便于医护人员在实际的诊断过程中输入新的诊断名称，并通过统一的格式定义新的诊断名称，便于系统的后续输入。In this embodiment, the diagnosis selection also includes adding a new diagnosis, and the new diagnosis defines the diagnosis code in a unified format, which is convenient for medical staff to input the new diagnosis name in the actual diagnosis process, and defines the new diagnosis name through the unified format, which is convenient for the medical staff to input the new diagnosis name in the actual diagnosis process. Subsequent inputs to the system.

进一步的，鉴别诊断待选级别包括全院级别和科室级别，由于同种疾病需要多个科室医护人员相互配合，因此科室级别可选择一个或多个科室，拟诊诊断用于设置当前诊断名称是否为拟诊诊断，便于科室的医护人员对诊断选择进行确认和修改，授权科室用于将诊断名称授权给至少一个科室，被授权的科室可以使用该诊断名称，未被授权的科室可以通过该设置拥有授权，配置鉴别诊断用于关联和显示所有适用于诊断名称的疾病名称，对当前做出的诊断名称进行关联，便于医护人员直接调取诊断名称对应的疾病名称，并再次确认患者的身体状况及诊断结果，减少医护人员的书写量，提高工作效率。Further, the levels to be selected for differential diagnosis include the hospital level and the department level. Since the same disease requires the cooperation of medical staff in multiple departments, one or more departments can be selected for the department level, and the proposed diagnosis is used to set whether the current diagnosis name is not. In order to make a diagnosis, it is convenient for the medical staff in the department to confirm and modify the diagnosis selection. The authorized department is used to authorize the diagnosis name to at least one department. The authorized department can use the diagnosis name, and the unauthorized department can use this setting. Possess authorization, configure differential diagnosis to associate and display all disease names applicable to the diagnosis name, and associate the current diagnosis name, so that the medical staff can directly retrieve the disease name corresponding to the diagnosis name, and reconfirm the patient's physical condition And diagnosis results, reduce the amount of writing for medical staff, improve work efficiency.

除此之外，诊断名称关联生成的多个疾病名称可以编辑诊断描述或删除，诊断描述用于医护人员将患者的身体状况及身体出现的症状做进一步详细的描述，删除疾病名称则是将不符合患者当前身体状况的疾病名称进行删除，使得该系统具有较高的可操作性和灵活的编辑能力，降低误诊错诊的概率。In addition, the multiple disease names generated by the association of the diagnosis name can be edited or deleted. The diagnosis description is used by medical staff to further describe the patient's physical condition and symptoms in detail. Deleting the disease name will not be used. The name of the disease that matches the current physical condition of the patient is deleted, which makes the system highly operable and flexible in editing, and reduces the probability of misdiagnosis and misdiagnosis.

如图2所示，该系统在使用的过程中包括以下步骤：As shown in Figure 2, the system includes the following steps during use:

S1：诊断选择，输入诊断名称；S1: Diagnosis selection, enter the diagnosis name;

S2：设置鉴别诊断待选级别为全院级别或科室级别，若选择全院级别则所有病区的科室均能使用输入的诊断名称，若选择科室级别则只有被选择的科室才能使用输入的诊断名称，且科室级别可以选择一个或多个；S2: Set the level to be selected for differential diagnosis as the hospital level or the department level. If the hospital level is selected, all departments in the ward can use the entered diagnosis name. If the department level is selected, only the selected department can use the input diagnosis. name, and one or more department levels can be selected;

S3：拟诊诊断，用于设置当前诊断名称是否为拟诊诊断；S3: Proposed diagnosis, used to set whether the current diagnosis name is a proposed diagnosis;

S4：授权科室，用于将当前诊断名称授权给至少一个科室；S4: Authorized department, used to authorize the current diagnosis name to at least one department;

S5：配置鉴别诊断，关联和显示所有适用于诊断名称的疾病名称，并生成每个疾病名称的选项，且能对每个疾病名称编辑诊断描述或删除不符合患者疾病症状的该疾病名称。S5: Configure differential diagnosis, associate and display all disease names applicable to the diagnosis name, and generate options for each disease name, and can edit the diagnosis description for each disease name or delete the disease name that does not match the patient's disease symptoms.

本实施例的电子病历诊断维护系统在使用时，通过诊断选择输入患者的诊断名称，选择鉴别诊断待选级别为全院级别或科室级别，判定拟诊诊断是否符合患者当前的疾病症状，选择授权科室所属医院的名称，选择配置鉴别诊断关联和显示所有适用于诊断名称的疾病名称，并生成每个疾病名称的选项，且能对每个疾病名称编辑诊断描述或删除，其中，诊断描述用于医护人员将患者的身体状况及身体出现的症状做进一步详细的描述，删除疾病名称则是将不符合患者当前疾病症状的疾病名称进行删除，使得该系统具有较高的可操作性和灵活的编辑能力，降低误诊错诊的概率，诊断名称与疾病名称进行关联，减少医护人员的书写病历的工作量，提高工作效率，便于普及和推广。When the electronic medical record diagnosis and maintenance system of this embodiment is in use, the diagnosis name of the patient is input through the diagnosis selection, and the level to be selected for the differential diagnosis is the hospital level or the department level. The name of the hospital to which the department belongs, choose to configure the differential diagnosis association and display all disease names applicable to the diagnosis name, and generate options for each disease name, and can edit or delete the diagnosis description for each disease name, where the diagnosis description is used for The medical staff will further describe the patient's physical condition and symptoms in detail, and deleting the disease name is to delete the disease name that does not conform to the patient's current disease symptoms, making the system highly operable and flexible for editing Ability to reduce the probability of misdiagnosis and misdiagnosis, the diagnosis name is associated with the disease name, reduce the workload of medical staff to write medical records, improve work efficiency, and facilitate popularization and promotion.

以上显示和描述了本发明的基本原理、主要特征和本发明的优点。本行业的技术人员应该了解，本发明不受上述实施例的限制，上述实施例和说明书中描述的仅为本发明的优选例，并不用来限制本发明，在不脱离本发明精神和范围的前提下，本发明还会有各种变化和改进，这些变化和改进都落入要求保护的本发明范围内。本发明要求保护范围由所附的权利要求书及其等效物界定。The foregoing has shown and described the basic principles, main features and advantages of the present invention. Those skilled in the art should understand that the present invention is not limited by the above-mentioned embodiments, and the above-mentioned embodiments and descriptions are only preferred examples of the present invention, and are not intended to limit the present invention, without departing from the spirit and scope of the present invention. Under the premise, the present invention will also have various changes and improvements, and these changes and improvements all fall within the scope of the claimed invention. The claimed scope of the present invention is defined by the appended claims and their equivalents.

Claims (5)

Translated fromChinese

1.一种电子病历诊断维护系统，其特征在于：所述系统包括：1. an electronic medical record diagnosis and maintenance system, is characterized in that: described system comprises:诊断选择，所述诊断选择用于选择诊断名称，所述诊断名称基于国家标准规范诊断编码；Diagnosis selection, the diagnosis selection is used to select a diagnosis name, and the diagnosis name is based on the national standard standard diagnosis code;鉴别诊断，所述鉴别诊断用于将当前诊断名称与其他疾病进行鉴别，并排除其他疾病的可能性，且所述鉴别诊断包括鉴别诊断待选级别、拟诊诊断、授权科室和配置鉴别诊断。Differential diagnosis, the differential diagnosis is used to distinguish the current diagnosis name from other diseases and exclude the possibility of other diseases, and the differential diagnosis includes the differential diagnosis candidate level, the proposed diagnosis, the authorized department and the configuration differential diagnosis.2.根据权利要求1所述的电子病历诊断维护系统，其特征在于：所述诊断选择还包括新增诊断，所述新增诊断按统一格式定义诊断编码。2 . The electronic medical record diagnosis and maintenance system according to claim 1 , wherein the diagnosis selection further comprises a newly added diagnosis, and the newly added diagnosis defines a diagnosis code in a unified format. 3 .3.根据权利要求1所述的电子病历诊断维护系统，其特征在于：所述鉴别诊断待选级别包括全院级别和科室级别；3. The electronic medical record diagnosis and maintenance system according to claim 1, characterized in that: said differential diagnosis candidate level comprises hospital level and department level;所述拟诊诊断用于设置当前诊断名称是否为拟诊诊断；The proposed diagnosis is used to set whether the current diagnosis name is the proposed diagnosis;所述授权科室用于将当前诊断名称授权给至少一个科室；The authorized department is used to authorize the current diagnosis name to at least one department;所述配置鉴别诊断用于关联和显示所有适用于所述诊断名称的疾病名称。The configured differential diagnosis is used to correlate and display all disease names that apply to the diagnosis name.4.根据权利要求3所述的电子病历诊断维护系统，其特征在于：所述科室级别可选择一个或多个科室。4 . The electronic medical record diagnosis and maintenance system according to claim 3 , wherein one or more departments can be selected for the department level. 5 .5.根据权利要求3所述的电子病历诊断维护系统，其特征在于：所述诊断名称关联生成的多个疾病名称可以编辑诊断描述或删除。5 . The electronic medical record diagnosis and maintenance system according to claim 3 , wherein the plurality of disease names generated by the association of the diagnosis names can be edited or deleted. 6 .

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