CN103778311A - Entry terminal and method for first-aid workstation structured electronic medical records - Google Patents
Entry terminal and method for first-aid workstation structured electronic medical records Download PDFInfo
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- CN103778311A CN103778311A CN201210401812.8A CN201210401812A CN103778311A CN 103778311 A CN103778311 A CN 103778311A CN 201210401812 A CN201210401812 A CN 201210401812A CN 103778311 A CN103778311 A CN 103778311A
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Abstract
The invention provides an entry terminal and method for first-aid workstation structured electronic medical records to solve the problem of low entry efficiency of first-aid workstation structured electronic medical records. The entry method comprises receiving key word instructions, matching a corresponding information list of the key word instructions according to the received key word instructions, wherein the information list comprises a plurality of information options; receiving information option instructions, and marking the corresponding information options according to the received information option instructions; generating electronic medical records automatically according to the marked information operations; saving the automatically generated electronic medical records; uploading the saved electronic medical records to a server. By means of the entry terminal and method, the entry efficiency of first-aid workstation structured electronic medical records is improved.
Description
Technical field
The present invention relates to medical field, particularly relate to a kind of typing terminal and input method of rescue service station structure electronic health record.
Background technology
At present in emergency medical rescue; in the time that patient is received at rescue service station; conventionally can carry out first aid to patient; but seldom typing patient's electronic health record; the mode of only record patient electronic health record still needs first-aid personnel manually to input series of symptoms; this has increased the time of case history typing undoubtedly, and because of the impact of first-aid personnel's individual factor, can cause the inadequate standard of case history recording on rescue service station.Not only efficiency of inputting is low for the input method of existing rescue service station electronic health record, and repeatability is high, also may typing mistake, cannot meet the demand of Rapid input Patients ' Electronic case history in rescue service station.And these medical record informations that recorded are very important in whole emergency medical rescue, can directly affect accurately work and the arrival hospital emergency relief scheme of Implementing Hospital afterwards of rescue of front hospital of arrival hospital before the arrival hospital of rescue service station.
Therefore, those skilled in the art's problem in the urgent need to address is: how to improve the efficiency of inputting of rescue service station electronic health record, realize the Rapid input of electronic health record.
Summary of the invention
The invention provides a kind of typing terminal and input method of rescue service station structure electronic health record, to solve the low problem of rescue service station electronic health record efficiency of inputting.
In order to address the above problem, the invention discloses a kind of typing terminal of rescue service station structure electronic health record, comprising:
Key word command reception module, for receiving key word instruction;
Information list matching module, mates information list corresponding to this key word instruction for the key word instruction receiving according to described key word command reception module, and described information list comprises multiple information options;
Information option command reception module, for receiving information option instruction;
Information option indicates module, indicates corresponding information option for the information option instruction receiving according to information option command reception module;
Electronic health record automatically-generating module, generates electronic health record automatically for the information option that indicates module sign according to described information option;
Electronic health record is preserved module, the electronic health record automatically generating for preserving described electronic health record automatically-generating module;
Transmission module on electronic health record, uploads onto the server for the electronic health record of described electronic health record being preserved to module preservation.
Preferably, also comprise:
Information list builds module, before receiving key word instruction, builds information list corresponding to all key word instructions, wherein, and a corresponding information list of key word instruction.
Preferably, also comprise:
Key word judge module, for automatically generate electronic health record according to the information option of described sign before, judge whether the key word instruction having received comprises all key words, if so, enter electronic health record automatically-generating module, otherwise return to key word command reception module.
Preferably, also comprise:
The sick command reception module of planting, plants instruction for receiving disease;
Matching module, for mating disease kind template corresponding to this disease kind instruction according to described sick disease kind instruction of planting the reception of command reception module, described sick kind in template comprises main suit, present illness history and important previous history information;
The sick electronic health record generation module of planting, for according to the main suit of the disease kind template of described coupling, present illness history and important previous history Automatic generation of information electronic health record.
Preferably, also comprise:
Modify instruction receiver module, for receiving modify instruction;
Information modified module, revises corresponding information for the modify instruction receiving according to described modify instruction receiver module;
Described information modified module comprises:
First revises submodule, when comprising corresponding information option when modify instruction, again indicates corresponding information option according to modify instruction;
Second revises submodule, for replacing and revise the front information option indicating according to modify instruction in the time that described modify instruction not comprising corresponding information option.
The input method that the invention also discloses a kind of rescue service station structure electronic health record, comprising:
Receive key word instruction, mate information list corresponding to this key word instruction according to the key word instruction of described reception, described information list comprises multiple information options;
Receive information option instruction, indicate corresponding information option according to the information option instruction receiving;
Automatically generate electronic health record according to the information option of described sign;
Preserve the electronic health record of described automatic generation;
The electronic health record of described preservation is uploaded onto the server.
Preferably, before the instruction of described reception key word, also comprise:
Build information list corresponding to all key word instructions, wherein, a corresponding information list of key word instruction.
Preferably, described automatically generate electronic health record according to the information option of described sign before, also comprise:
Whether the key word instruction that judgement has received comprises all key words, if so, automatically generates electronic health record according to the information option of described sign, otherwise continues to receive key word instruction.
Preferably, also comprise:
Receive the sick instruction of planting, mate disease kind template corresponding to this disease kind instruction according to the disease kind instruction of described reception, described sick kind in template comprises main suit, present illness history and important previous history information;
According to the main suit in the disease kind template of described coupling, present illness history and important previous history Automatic generation of information electronic health record.
Preferably, before the described electronic health record by preservation uploads onto the server, also comprise:
Receive modify instruction;
Revise corresponding information according to the modify instruction of described reception;
The described modify instruction according to described reception is revised corresponding information and is comprised:
Again the information option that beacon information option or replacement indicate before revising, in the time that modify instruction comprises corresponding information option, indicates corresponding information option again according to modify instruction, otherwise, replace the information option indicating before modification according to modify instruction.
Compared with prior art, the present invention includes following advantage:
Information list corresponding to this key word instruction mated in the key word instruction that the present invention receives according to key word command reception module, and described information list comprises multiple information options, has realized the structuring typing of electronic health record; The information option instruction that the present invention receives according to information option command reception module indicates corresponding information option, has avoided case history to describe disunity, has saved the time of case history typing simultaneously; The information option that the present invention indicates module sign according to information option generates electronic health record automatically, has improved the efficiency of inputting of rescue service station electronic health record; The electronic health record that typing terminal of the present invention is preserved electronic health record module preservation in the process of driving towards hospital uploads onto the server, and has realized the renewal to Patients ' Electronic case history.
Accompanying drawing explanation
Fig. 1 is the structured flowchart of the typing terminal of a kind of rescue service station structure of embodiment of the present invention electronic health record;
Fig. 2 is the schematic diagram of information list corresponding to embodiment of the present invention key word instruction;
Fig. 3 is the electronic health record that embodiment of the present invention electronic health record automatically-generating module generates;
Fig. 4 is the structured flowchart of the typing terminal of the another kind of rescue service station structure of embodiment of the present invention electronic health record;
Fig. 5 is the sick schematic diagram of planting instruction of the embodiment of the present invention;
Fig. 6 is the matching result schematic diagram of embodiment of the present invention matching module;
Fig. 7 is a kind of first aid process flow diagram of the embodiment of the present invention;
Fig. 8 is the schematic diagram of embodiment of the present invention first aid instruction;
Fig. 9 is the configuration diagram of embodiment of the present invention first aid communication system;
Figure 10 is the process flow diagram of the input method of a kind of rescue service station structure of embodiment of the present invention electronic health record;
Figure 11 is the process flow diagram of the input method of the another kind of rescue service station structure of embodiment of the present invention electronic health record.
Embodiment
For above-mentioned purpose of the present invention, feature and advantage can be become apparent more, below in conjunction with the drawings and specific embodiments, the present invention is further detailed explanation.
Embodiment mono-:
With reference to Fig. 1, show the structured flowchart of the typing terminal of a kind of rescue service station structure of the present invention electronic health record, the present embodiment specifically can comprise with lower module:
Key word command reception module 101, for receiving key word instruction.
In the present embodiment, key word instruction can be: cardinal symptom, the main concomitant symptoms, duration etc., the wherein corresponding information list of each key word instruction.As shown in Figure 2, when key word instruction is cardinal symptom, corresponding information list comprises: consciousness changing, faint, uncomfortable in chest, pectoralgia, palpitaition, headache, dizziness, weak, nervous etc.; When key word instruction is the main concomitant symptoms, corresponding information list comprises: consciousness changing, faint, uncomfortable in chest, pectoralgia, palpitaition, headache, dizziness, weak, nervous etc.; When key word instruction is the duration, corresponding information list comprises numeral and unit.
It should be noted that, the key word instruction in the present embodiment divide be chief complaint, present illness history and important previous history three classes, main suit's key word instruction comprises cardinal symptom, the main concomitant symptoms, duration; The key word instruction of present illness history comprises select time, selects to have or not the negative symptoms of inducement, cardinal symptom, simultaneous phenomenon, discriminating meaning, selects to have or not treatment, certain symptom to select to have or not alleviation; The key word instruction of important previous history comprises previous history and drug allergy medical history.
In Fig. 2, only listed the partial content of information list, in Fig. 2, the content of listed information list should not served as limitation of the present invention.
Information list matching module 102, mates information list corresponding to this key word instruction for the key word instruction receiving according to described key word command reception module, and described information list comprises multiple information options.
With reference to Fig. 2, consciousness changing that above-mentioned information list comprises, faint, uncomfortable in chest, pectoralgia, palpitaition, headache, dizziness, weak, nervous etc., be all information option.Corresponding information list is mated in the key word instruction that information list matching module 102 receives according to key word command reception module 101, for example, when the key word instruction receiving is cardinal symptom, coupling cardinal symptom information list, cardinal symptom information list comprises consciousness changing, faints, uncomfortable in chest, pectoralgia, palpitaition, headache, dizziness, multiple information options such as weak, nervous.
It should be noted that, in the present embodiment, information option also may comprise second-level message option, as having arrow after information option pectoralgia in Fig. 2
mark, this information option pectoralgia comprises second-level message option: after chest, breastbone, pareordia, right chest, left chest.
Information option command reception module 103, for receiving information option instruction.
The information option instruction that information option command reception module 103 receives equally also comprises the instruction of second-level message option.
Information option indicates module 104, indicates corresponding information option for the information option instruction receiving according to information option command reception module.
In the present embodiment, if the information option instruction that information option command reception module 103 receives is palpitaition, information option sign module 104 indicates information option palpitaition, and the information option after sign there will be the relevant position at electronic health record.
Electronic health record automatically-generating module 105, generates electronic health record automatically for the information option that indicates module sign according to described information option.
Shown in Fig. 3, information option indicates that main suit's information option of indicating of module 104 is after breastbone, pain, companion's lethargic sleep, 28 minutes; Information option indicate the present illness history information option that indicates of module 104 be before 2 days, without obvious inducement, chest, constant pain, uncomfortable in chest, without nosebleed, not treatment, nosebleed, without alleviating; The important previous history information option that information option sign module 104 indicates is disease 4 years, allergy.Information option after electronic health record automatically-generating module 105 indicates these generates electronic health record automatically: retrosternal pain, companion's lethargic sleep approximately 28 minutes; Under the obvious inducement of patient's nothing before 2 days: chest constant pain.Accompany uncomfortable in chest.Without nosebleed.After this morbidity, do not treat.Nosebleed is without alleviation; Disease approximately 4 years, drug allergy history is irritated.
In the present embodiment, electronic health record automatically-generating module 105 can indicate the information option that module 104 indicates according to information option and automatically generate electronic health record, has improved the efficiency of inputting of electronic health record.
Electronic health record is preserved module 106, the electronic health record automatically generating for preserving described electronic health record automatically-generating module.
Electronic health record is preserved module 106 and immediately automatic electronic health record automatically-generating module 105 electronic health record generating is saved to typing terminal, has avoided the loss of electronic health record data.Described electronic health record is preserved module and in Fig. 2, is presented as preservation case history.
Transmission module 107 on electronic health record, uploads onto the server for the electronic health record of described electronic health record being preserved to module preservation.
On electronic health record, transmission module 107 is preserved by electronic health record the electronic health record that module 106 preserves and is uploaded onto the server, and has realized the renewal to Patients ' Electronic case history.On described electronic health record, transmission module is presented as submission case history in Fig. 2.
Information list corresponding to this key word instruction mated in the key word instruction that in the present embodiment, information list matching module 102 receives according to key word command reception module 101, and described information list comprises multiple information options, realized the structuring typing of electronic health record; The information option instruction that the present embodiment information option sign module 104 receives according to information option command reception module 103 indicates corresponding information option, has avoided case history to describe disunity, has saved the time of case history typing simultaneously; The information option that in the present embodiment, electronic health record automatically-generating module 105 indicates according to information option sign module 104 generates electronic health record automatically, has improved the efficiency of inputting of rescue service station electronic health record; In the present embodiment on electronic health record transmission module 107 in the process of driving towards hospital, electronic health record is preserved module preserve electronic health record upload onto the server, realized the renewal of Patients ' Electronic case history.
Embodiment bis-:
With reference to Fig. 4, show the structured flowchart of the typing terminal of the another kind of rescue service station structure of the present invention electronic health record, the present embodiment specifically can comprise with lower module:
Information list builds module 201, before receiving key word instruction, builds information list corresponding to all key word instructions.
When information list structure module 201 builds information list, a corresponding information list of key word instruction.For example, when key word instruction is cardinal symptom, corresponding information list is list one, comprises: consciousness changing, faint, uncomfortable in chest, pectoralgia, palpitaition, headache, dizziness, weak, nervous; When key word instruction is the main concomitant symptoms, corresponding information list is list two, comprises: consciousness changing, faint, uncomfortable in chest, pectoralgia, palpitaition, headache, dizziness, weak, nervous etc.; When key word instruction is the duration, corresponding information list is list three, comprises numeral and unit.
Key word command reception module 202, for receiving key word instruction.
In the present embodiment, key word instruction divide be chief complaint, present illness history and important previous history three classes, main suit's key word instruction comprises cardinal symptom, the main concomitant symptoms, duration; The key word instruction of present illness history comprises select time, selects to have or not the negative symptoms of inducement, cardinal symptom, simultaneous phenomenon, discriminating meaning, selects to have or not treatment, certain symptom to select to have or not alleviation; The key word instruction of important previous history comprises previous history and drug allergy medical history.
Information list matching module 203, mates information list corresponding to this key word instruction for the key word instruction receiving according to described key word command reception module, and described information list comprises multiple information options.
With reference to Fig. 2, consciousness changing that above-mentioned information list comprises, faint, uncomfortable in chest, pectoralgia, palpitaition, headache, dizziness, weak, nervous etc., be all information option.Corresponding information list is mated in the key word instruction that information list matching module 203 receives according to key word command reception module 202, for example, when the key word instruction receiving is cardinal symptom, coupling cardinal symptom information list, cardinal symptom information list comprises consciousness changing, faints, uncomfortable in chest, pectoralgia, palpitaition, headache, dizziness, multiple information options such as weak, nervous.
Information option command reception module 204, for receiving information option instruction.
Information option instruction comprises above-mentioned one or more information option.
Information option indicates module 205, indicates corresponding information option for the information option instruction receiving according to information option command reception module.
In the present embodiment, if the information option instruction that information option command reception module 204 receives is palpitaition, information option sign module 205 indicates information option palpitaition, and the information option after sign there will be the relevant position at electronic health record.
Key word judge module 206, for automatically generate electronic health record according to the information option of described sign before, judge whether the key word instruction having received comprises all key words, if so, enter electronic health record automatically-generating module, otherwise return to key word command reception module.
For guaranteeing the complete and accurate of electronic health record, the present embodiment comprises key word judge module 206, after receiving all key word instructions, enters electronic health record automatically-generating module 207.Here all key word instructions comprise above-mentioned main suit, present illness history and the three class key word instructions of important previous history.
Electronic health record automatically-generating module 207, generates electronic health record automatically for the information option that indicates module sign according to described information option.
Shown in Fig. 3, information option indicates that main suit's information option of indicating of module 205 is after breastbone, pain, companion's lethargic sleep, 28 minutes; Information option indicate the present illness history information option that indicates of module 205 be before 2 days, without obvious inducement, chest, constant pain, uncomfortable in chest, without nosebleed, not treatment, nosebleed, without alleviating; The important previous history information option that information option sign module 205 indicates is disease 4 years, allergy.Information option after electronic health record automatically-generating module 207 indicates these generates electronic health record automatically: retrosternal pain, companion's lethargic sleep approximately 28 minutes; Under the obvious inducement of patient's nothing before 2 days: chest constant pain.Accompany uncomfortable in chest.Without nosebleed.After this morbidity, do not treat.Nosebleed is without alleviation; Disease approximately 4 years, drug allergy history is irritated.
In the present embodiment, electronic health record automatically-generating module 207 can indicate the information option that module 205 indicates according to information option and automatically generate electronic health record, has improved the efficiency of inputting of electronic health record.
The sick command reception module 208 of planting, plants instruction for receiving disease;
With reference to Fig. 5, show 7 kinds of sick kinds instruction in the present embodiment.Specifically comprise: heart arrest: quiver in chamber, heart arrest: pulseless electrocardio-activity or ventricular asystole, pectoralgia, uncomfortable in chest: heart stalk, senseless: critical cerebrovas-cularaccident, limb adynamia: general cerebrovas-cularaccident, trauma pain: craniocerebral trauma, trauma pain: limb trauma.
Matching module 209, for mating disease kind template corresponding to this disease kind instruction according to described sick disease kind instruction of planting the reception of command reception module, described sick kind in template comprises main suit, present illness history and important previous history information;
For example, the disease kind instruction that sick kind command reception module 208 receives is " heart arrest: quiver in chamber ", this disease kind instruction heart arrest of matching module 209 Auto-matchings: the chamber corresponding heart arrest of quivering: the chamber disease of quivering is planted template, the sick template of planting comprises main suit, present illness history and important previous history information, particularly, the heart arrest that matching module 209 matches: disease kind template is quivered as shown in Figure 6 in chamber, be specially main suit: senseless 10 minutes, present illness history: patient is without obviously inducement is senseless suddenly before 10 minutes, and that exhales should not.Gatism, nothing vomiting, nothing are twitched.Emergency treatment voluntarily not after morbidity.Important previous history: coronary heart disease (or hypertension or old-slow-bronchial tube) more than 10 years.
The sick electronic health record generation module 210 of planting, for according to the main suit of the disease kind template of described coupling, present illness history and important previous history Automatic generation of information electronic health record.
Can be found out by foregoing description, receive the sick instruction of planting by disease kind command reception module 208, matching module 209 mates main suit, present illness history and important previous history information, then the sick electronic health record generation module 210 of planting is according to the main suit of described coupling, present illness history and important previous history Automatic generation of information electronic health record, build module 201 to electronic health record automatically-generating module 207 compared to information list, typing is more efficient and convenient.
Electronic health record is preserved module 211, for preserving described electronic health record automatically-generating module or the sick electronic health record generation module electronic health record of generation automatically of planting.
Electronic health record is preserved module 211 and immediately electronic health record automatically-generating module 207 or the sick automatic electronic health record generating of electronic health record generation module 210 of planting is saved to typing terminal, has avoided the loss of electronic health record data.
Modify instruction receiver module 212, for receiving modify instruction;
In the present embodiment, modify instruction receiver module 212 is for before transmission module on electronic health record 214, and modify instruction can inclusion information option, also can be not limited to information option but specific descriptions to the state of an illness.
Information modified module 213, revises corresponding information for the modify instruction receiving according to described modify instruction receiver module;
For example, take Fig. 6 as example, the modify instruction that modify instruction receiver module 212 receives is: senseless 15 minutes of main suit, " senseless 15 minutes " are revised as in the main suit in electronic health record " senseless 10 minutes ".Information modified module 213 can, according to the variation real time modifying electronic health record of conditions of patients, guarantee the accurate typing of electronic health record.
Described information modified module 213 comprises:
First revises submodule 2131, when comprising corresponding information option when modify instruction, again indicates corresponding information option according to modify instruction;
Take Fig. 3 as example, if the modify instruction that modify instruction receiver module 212 receives is: main suit's precordialgia, the information option that comprises secondary by pectoralgia: after chest, breastbone, pareordia, right chest, left chest, can find out that modify instruction includes corresponding information option pareordia, first revises submodule 2131 re-starts sign to information option, namely indicate " pareordia ", retrosternal pain is just revised as precordialgia like this.
Second revises submodule 2132, for replacing and revise the front information option indicating according to modify instruction in the time that described modify instruction not comprising corresponding information option.
Take Fig. 3 as example, if the modify instruction that modify instruction receiver module 212 receives is: right-hand pain after main suit's breastbone, the information option that comprises secondary by pectoralgia: after chest, breastbone, pareordia, right chest, left chest, can find out not " right-hand after breastbone " this information option, namely modify instruction does not have corresponding information option, and second revises submodule 2132 replaces and revise the front information option " after breastbone " indicating according to modify instruction " right-hand after breastbone ".
Transmission module 214 on electronic health record, uploads onto the server for the electronic health record of described electronic health record being preserved to module preservation.
On electronic health record, transmission module 214 is preserved by electronic health record the electronic health record that module 211 preserves and is uploaded onto the server, and has realized the renewal of Patients ' Electronic case history.On described electronic health record, transmission module is presented as submission case history in Fig. 2.
The present embodiment is planted command reception module 208 by disease and is received the sick instruction of planting, matching module 209 mates main suit, present illness history and important previous history information, then the sick electronic health record generation module 210 of planting, according to the main suit of described coupling, present illness history and important previous history Automatic generation of information electronic health record, has improved the efficiency of inputting of electronic health record.
Embodiment tri-:
With reference to Fig. 7, show a kind of first aid process flow diagram of the present invention, the present embodiment specifically can comprise the following steps:
S701, awaits orders in awaiting orders or stand in way.
Emergency tender is not in the time receiving first aid instruction, on the way or wait in station and receive first aid instruction.
S702, receives instruction.
Emergency tender receives the first aid instruction that emergency command center sends, as shown in Figure 8, and essential information, the state of an illness, the particular location that first aid instruction comprises patient and the hospital being sent to.Patient's essential information comprises name, age, sex, identity, contact person, telephone number of patient etc.Patient's the state of an illness comprises severity extent and main suit.Particular location comprises patient's site address and the patient address of waiting for bus, and in Fig. 8, site address is: 108 Room 12,1st floor, building of bypass Xi Man, south, Zhongcun Road, and the address of waiting for bus is: 108 Room 12,1st floor, building of bypass Xi Man, south, Zhongcun Road, be sent to address and be: Minxing District central hospital.
S703, drives towards scene.
Emergency tender sails to the address of waiting for bus in the first aid instruction receiving, and driving towards in on-the-spot process, does corresponding first aid prepare according to the conditions of patients in first aid instruction, comprises and prepares first aid medicine and prepare first-aid apparatus.
S704, reaches the spot.
S705, patient gets on the bus.
Emergency tender arrives the scene at patient place, and first-aid personnel transfers to patient on emergency tender.
Get on the bus and arrive in the process of hospital to emergency tender patient, first-aid personnel carries out first aid to patient, the typing terminal fast recording patient's of the structured electronic patient record on emergency tender detailed case history.
The typing terminal of the rescue service station structure electronic health record described in the embodiment of the present invention one and embodiment bis-is arranged on emergency tender, and after patient is received on emergency tender, before arriving hospital, carry out typing Patients ' Electronic case history, and the electronic health record of institute's typing is uploaded to central server, the real-time electronic case history that doctor in hospital can logon server checks patient, carrying out corresponding first aid prepares, saved valuable rescue time, the patient medical record of obtaining detailed complete for patient's timely and effective treatment and doctor provides reliable guarantee.
S706, arrives hospital.
Emergency tender arrives after hospital, and patient is transferred to first-aid room, and doctor carries out first aid to patient.Emergency tender re-starts awaits orders, and namely returns to step S701.
Below in conjunction with Fig. 9, above-mentioned first aid process is further illustrated, described system architecture mainly comprises following a few part:
Central server 31, emergency command center 32, first-aid centre's operator attendance 33, first-aid station of hospital 34, moving first-aid station 35 and emergency tender 36.
Wherein, central server 31 is the mobile hinges of system data, completes processing and the forwarding of various data, mainly processes that identification authentication, data are synchronous, data are preserved and data retransmission.Central server 31 can be processed several data, as SIP (Session Initiation Protocol, by ietf definition, an IP-based application layer control protocol) message, RTP (Real-time Transport Protocol, RTP) instruction, RTSP (Real Time Streaming Protocol, real-time streaming protocol) instruction, audio, video data, physiological data, GPS (Global Positioning System, GPS) data etc.Various data in described first aid communication system are generally all passed through the forwarding of central server 31.
Emergency command center 32 completes unified command scheduling, and emergency command center 32 computing machines send first aid instruction, and obtains gps data, patient's the information such as audio frequency and video and physiological data from central server.First-aid centre's operator attendance 33 can be consulted related data by central server 31, manually coordinates emergency command center 32 to dispatch.
First-aid station of hospital 34 Main Analysis and check from patient's collection in worksite to situation, these data mainly contain on-the-spot audio frequency and video, patient's audio frequency and video, patient's physiological data, for example blood pressure, blood oxygen, the rhythm of the heart, temperature etc., also has patient's case history, medication materials, patient's doctor's advice etc.
Moving first-aid station 35 and emergency tender 36 are a unified system, wherein, and the typing terminal of the rescue service station structure electronic health record described in the emergency tender 36 deploy embodiment of the present invention one and embodiment bis-.The first aid instruction appointment emergency tender 36 of emergency command center 32 is received at moving first-aid station 35, the typing terminal of the rescue service station structure electronic health record of emergency tender 36 deploy, for gathering the various data at patient scene the real-time electronic case history of record patient, process in real time and pass to first-aid station of hospital 34 by central server 31.
Following client can also be disposed in emergency tender 36:
Common camera, for gathering the road conditions outside situation and the car in emergency tender;
High-definition camera, for gathering patient's real-time imaging;
Patient monitor, for gathering patient physiological data;
GPS locating module, for locating the position on emergency tender;
Barcode scanner, adds up clearing for the patient's medication materials to first aid process;
With the access device of touch-screen, for controlling described common shooting, high-definition camera, patient monitor, GPS positioning module and barcode scanner, and first aid field data is real-time transmitted to policy control and dispatching system.
In addition, responsible departments of the government can also directly consult all data by central server 31, to understand whole first aid process.
The processing of first aid communication system is as follows:
After patient is ill, dial ambulance call, emergency command center 32 is received phone incoming call, produces first aid event, and sends first aid instruction; Central server 31 receives the instruction sending from emergency command center 32, and instruction is sent to moving first-aid station 35, starts working after receiving instruction in moving first-aid station 35, assigns emergency tender 36; Emergency tender 36 collection site data, as patient audio/video, patient physiological data, patient's medication materials situation, patient's the information such as electronic health record, doctor's advice, and field data is returned to central server 31, central server 31 is transmitted to data processing first-aid station of hospital 34 again; First-aid station of hospital 34 organizes related doctor to hold a consultation, and after patient delivers to hospital, carries out corresponding point at once examine according to consultation of doctors result.
Embodiment tetra-:
With reference to Figure 10, show the process flow diagram of the input method of a kind of rescue service station structure of the present invention electronic health record, the present embodiment specifically can comprise the following steps:
S1001, receives key word instruction, mates information list corresponding to this key word instruction according to the key word instruction of described reception, and described information list comprises multiple information options.
In the present embodiment, key word instruction can be: cardinal symptom, the main concomitant symptoms, duration etc., the wherein corresponding information list of each key word instruction.As shown in Figure 2, for example, when the key word instruction receiving is cardinal symptom, coupling cardinal symptom information list, cardinal symptom information list comprises consciousness changing, faints, uncomfortable in chest, pectoralgia, palpitaition, headache, dizziness, multiple information options such as weak, nervous.
It should be noted that, the key word instruction in the present embodiment divide be chief complaint, present illness history and important previous history three classes, main suit's key word instruction comprises cardinal symptom, the main concomitant symptoms, duration; The key word instruction of present illness history comprises select time, selects to have or not the negative symptoms of inducement, cardinal symptom, simultaneous phenomenon, discriminating meaning, selects to have or not treatment, certain symptom to select to have or not alleviation; The key word instruction of important previous history comprises previous history and drug allergy medical history.
It should be noted that, in the present embodiment, information option also may comprise second-level message option, as having arrow after information option pectoralgia in Fig. 2
mark, this information option pectoralgia comprises second-level message option: after chest, breastbone, pareordia, right chest, left chest.
In Fig. 2, only listed the partial content of information list, in Fig. 2, the content of listed information list should not served as limitation of the present invention.
S1002, receives information option instruction, indicates corresponding information option according to the information option instruction receiving.
Originally be that the information option instruction that embodiment receives comprises above-mentioned one or more information option, equally also comprise the instruction of second-level message option.In the time that the information option instruction receiving is palpitaition, information option palpitaition is indicated, the information option after sign there will be the relevant position at electronic health record.
S1003, generates electronic health record automatically according to the information option of described sign.
Shown in Fig. 3, the main suit's information option indicating according to the information option instruction that receives in S1002 is after breastbone, pain, companion's lethargic sleep, 28 minutes; The present illness history information option indicating was before 2 days, without obvious inducement, chest, constant pain, uncomfortable in chest, without nosebleed, not treatment, nosebleed, without alleviating; The important previous history information option indicating is disease 4 years, allergy.Information option after these being indicated in S1003 generates electronic health record automatically: retrosternal pain, companion's lethargic sleep approximately 28 minutes; Under the obvious inducement of patient's nothing before 2 days: chest constant pain.Accompany uncomfortable in chest.Without nosebleed.After this morbidity, do not treat.Nosebleed is without alleviation; Disease approximately 4 years, drug allergy history is irritated.
In the present embodiment, automatically generate electronic health record according to the information option of described sign, improved the efficiency of inputting of electronic health record.
S1004, preserves the electronic health record of described automatic generation;
The present embodiment is immediately saved to typing terminal by the electronic health record automatically generating in S1003, has avoided the loss of electronic health record data.This step S1004 is presented as preservation case history in Fig. 2.
S1005, uploads onto the server the electronic health record of described preservation.
The present embodiment uploads onto the server the electronic health record of preserving in S 1004, has realized the renewal to Patients ' Electronic case history.This step S1005 is presented as submission case history in Fig. 2.
The present embodiment mates information list corresponding to this key word instruction according to the key word instruction receiving, and described information list comprises multiple information options, has realized the structuring typing of electronic health record; The present embodiment indicates corresponding information option according to the information option instruction receiving, and has avoided case history to describe disunity, has saved the time of case history typing simultaneously; The present embodiment generates electronic health record automatically according to the information option indicating in S 1002, has improved the efficiency of inputting of rescue service station electronic health record; The electronic health record of preserving in S1004 is uploaded onto the server, realized the renewal to Patients ' Electronic case history.
For embodiment of the method, because it is substantially similar to device embodiment, so description is fairly simple, relevant part is referring to the part explanation as Fig. 1 device embodiment.
Embodiment five:
With reference to Figure 11, show the process flow diagram of the input method of the another kind of rescue service station structure of the present invention electronic health record, the present embodiment specifically can comprise the following steps:
S1101, builds information list corresponding to all key word instructions, wherein, and a corresponding information list of key word instruction.
While building information list in the present embodiment, a corresponding information list of key word instruction.For example, when key word instruction is cardinal symptom, corresponding information list is list one, comprises: consciousness changing, faint, uncomfortable in chest, pectoralgia, palpitaition, headache, dizziness, weak, nervous; When key word instruction is the main concomitant symptoms, corresponding information list is list two, comprises: consciousness changing, faint, uncomfortable in chest, pectoralgia, palpitaition, headache, dizziness, weak, nervous etc.; When key word instruction is the duration, corresponding information list is list three, comprises numeral and unit.
S1102, receives key word instruction, mates information list corresponding to this key word instruction according to the key word instruction of described reception, and described information list comprises multiple information options.
In the present embodiment, key word instruction divide be chief complaint, present illness history and important previous history three classes, main suit's key word instruction comprises cardinal symptom, the main concomitant symptoms, duration; The key word instruction of present illness history comprises select time, selects to have or not the negative symptoms of inducement, cardinal symptom, simultaneous phenomenon, discriminating meaning, selects to have or not treatment, certain symptom to select to have or not alleviation; The key word instruction of important previous history comprises previous history and drug allergy medical history.
With reference to Fig. 2, consciousness changing that above-mentioned information list comprises, faint, uncomfortable in chest, pectoralgia, palpitaition, headache, dizziness, weak, nervous etc., be all information option.In the time that the key word instruction receiving is cardinal symptom, coupling cardinal symptom information list, cardinal symptom information list comprises consciousness changing, faints, uncomfortable in chest, pectoralgia, palpitaition, headache, dizziness, multiple information options such as weak, nervous.
S1103, receives information option instruction, indicates corresponding information option according to the information option instruction receiving.
Information option instruction comprises above-mentioned one or more information option.In the present embodiment, if the information option instruction receiving is palpitaition, information option palpitaition is indicated, the information option after sign there will be the relevant position at electronic health record.
S1104, whether the key word instruction that judgement has received comprises all key words, if so, automatically generates electronic health record according to the information option of described sign, otherwise continues to receive key word instruction.
For guaranteeing the complete and accurate of electronic health record, the present embodiment is after receiving all key word instructions, and execution step S1105 generates electronic health record automatically according to the information option of described sign.Here all key word instructions comprise above-mentioned main suit, present illness history and the three class key word instructions of important previous history.
S1105, generates electronic health record automatically according to the information option of described sign.
Shown in Fig. 3, the main suit's information option indicating in step S1003 is after breastbone, pain, companion's lethargic sleep, 28 minutes; The present illness history information option indicating was before 2 days, without obvious inducement, chest, constant pain, uncomfortable in chest, without nosebleed, not treatment, nosebleed, without alleviating; The important previous history information option indicating is disease 4 years, allergy.Information option after these being indicated in step S1005 generates electronic health record automatically: retrosternal pain, companion's lethargic sleep approximately 28 minutes; Under the obvious inducement of patient's nothing before 2 days: chest constant pain.Accompany uncomfortable in chest.Without nosebleed.After this morbidity, do not treat.Nosebleed is without alleviation; Disease approximately 4 years, drug allergy history is irritated.
The present embodiment can generate electronic health record automatically according to the information option indicating, and has improved the efficiency of inputting of electronic health record.
S1106, receives the sick instruction of planting, and mates disease kind template corresponding to this disease kind instruction according to the disease kind instruction of described reception.
Described in the present embodiment, sick kind in template comprises main suit, present illness history and important previous history information.
With reference to Fig. 5, show 7 kinds of sick kinds instruction in the present embodiment.Specifically comprise: heart arrest: quiver in chamber, heart arrest: pulseless electrocardio-activity or ventricular asystole, pectoralgia, uncomfortable in chest: heart stalk, senseless: critical cerebrovas-cularaccident, limb adynamia: general cerebrovas-cularaccident, trauma pain: craniocerebral trauma, trauma pain: limb trauma.
If the disease kind instruction receiving is " heart arrest: quiver in chamber ", this disease kind instruction heart arrest of Auto-matching: the chamber corresponding heart arrest of quivering: the chamber disease of quivering is planted template, the sick template of planting comprises main suit, present illness history and important previous history information, the heart arrest specifically matching: disease kind template is quivered as shown in Figure 6 in chamber, be specially main suit: senseless 10 minutes, present illness history: patient is without obviously inducement is senseless suddenly before 10 minutes, and that exhales should not.Gatism, nothing vomiting, nothing are twitched.Emergency treatment voluntarily not after morbidity.Important previous history: coronary heart disease (or hypertension or old-slow-bronchial tube) more than 10 years.
S1107, according to the main suit in the disease kind template of described coupling, present illness history and important previous history Automatic generation of information electronic health record.
Can be found out by foregoing description, receive the sick instruction of planting by step S1106, coupling main suit, present illness history and important previous history information, then pass through step S1107 according to the main suit of described coupling, present illness history and important previous history Automatic generation of information electronic health record, generate electronic health record compared to information step S1101 to step S1105, more efficient and convenient.
S1108, preserves the electronic health record of described automatic generation.
In the present embodiment, the electronic health record of above-mentioned automatic generation comprises according to the information option of described sign and automatically generates electronic health record, or, according to the main suit in the disease kind template of described coupling, present illness history and important previous history Automatic generation of information electronic health record.Immediately the electronic health record of above-mentioned automatic generation is saved to typing terminal, can have avoided the loss of electronic health record data.
S1109, receives modify instruction.
Before step S1111 uploads onto the server the electronic health record of described preservation, accept modify instruction, in the present embodiment, modify instruction can inclusion information option, also can be not limited to information option but specific descriptions to the state of an illness.
S1110, revises corresponding information according to the modify instruction of described reception.
For example, take Fig. 6 as example, modify instruction is: senseless 15 minutes of main suit, " senseless 15 minutes " are revised as in the main suit in electronic health record " senseless 10 minutes ".Revise corresponding information according to the modify instruction of described reception, guaranteed the accurate typing of electronic health record.
In the present embodiment, revising corresponding information according to the modify instruction of described reception specifically comprises:
Again the information option that beacon information option or replacement indicate before revising, in the time that modify instruction comprises corresponding information option, indicates corresponding information option again according to modify instruction, otherwise, replace the information option indicating before modification according to modify instruction.
Take Fig. 3 as example, if the modify instruction receiving is: main suit's precordialgia, the information option that comprises secondary by pectoralgia: after chest, breastbone, pareordia, right chest, left chest, can find out that modify instruction includes corresponding information option pareordia, again indicate corresponding information option according to modify instruction, namely indicate " pareordia ", retrosternal pain is just revised as precordialgia like this.
Equally take Fig. 3 as example, if the modify instruction receiving is: right-hand pain after main suit's breastbone, the information option that comprises secondary by pectoralgia: after chest, breastbone, pareordia, right chest, left chest, can find out not " right-hand after breastbone " this information option, namely modify instruction does not have corresponding information option, replace and revise the front information option indicating according to modify instruction, use modify instruction " right-hand after breastbone " to replace the information option " after breastbone " indicating before modification.
S1111, uploads onto the server the electronic health record of described preservation.
The electronic health record of preservation is uploaded onto the server, realized the renewal of Patients ' Electronic case history.Described step S1111 uploads onto the server the electronic health record of preservation in Fig. 2, to be presented as submission case history.
The present embodiment receives the sick instruction of planting by step S1106, coupling main suit, present illness history and important previous history information, then pass through step S1107 according to the main suit of described coupling, present illness history and important previous history Automatic generation of information electronic health record, improved the efficiency of inputting of electronic health record.
For embodiment of the method, because it is substantially similar to device embodiment, so description is fairly simple, relevant part is referring to the part explanation as Fig. 4 device embodiment.
Each embodiment in this instructions all adopts the mode of going forward one by one to describe, and what each embodiment stressed is and the difference of other embodiment, between each embodiment identical similar part mutually referring to.
Typing terminal and input method to a kind of rescue service station structure electronic health record provided by the present invention above, be described in detail, applied specific case herein principle of the present invention and embodiment are set forth, the explanation of above embodiment is just for helping to understand method of the present invention and core concept thereof; , for one of ordinary skill in the art, according to thought of the present invention, all will change in specific embodiments and applications, in sum, this description should not be construed as limitation of the present invention meanwhile.
Claims (10)
1. a typing terminal for rescue service station structure electronic health record, is characterized in that, comprising:
Key word command reception module, for receiving key word instruction;
Information list matching module, mates information list corresponding to this key word instruction for the key word instruction receiving according to described key word command reception module, and described information list comprises multiple information options;
Information option command reception module, for receiving information option instruction;
Information option indicates module, indicates corresponding information option for the information option instruction receiving according to information option command reception module;
Electronic health record automatically-generating module, generates electronic health record automatically for the information option that indicates module sign according to described information option;
Electronic health record is preserved module, the electronic health record automatically generating for preserving described electronic health record automatically-generating module;
Transmission module on electronic health record, uploads onto the server for the electronic health record of described electronic health record being preserved to module preservation.
2. terminal according to claim 1, is characterized in that, also comprises:
Information list builds module, before receiving key word instruction, builds information list corresponding to all key word instructions, wherein, and a corresponding information list of key word instruction.
3. terminal according to claim 1, is characterized in that, also comprises:
Key word judge module, for automatically generate electronic health record according to the information option of described sign before, judge whether the key word instruction having received comprises all key words, if so, enter electronic health record automatically-generating module, otherwise return to key word command reception module.
4. terminal according to claim 1, is characterized in that, also comprises:
The sick command reception module of planting, plants instruction for receiving disease;
Matching module, for mating disease kind template corresponding to this disease kind instruction according to described sick disease kind instruction of planting the reception of command reception module, described sick kind in template comprises main suit, present illness history and important previous history information;
The sick electronic health record generation module of planting, for according to the main suit of the disease kind template of described coupling, present illness history and important previous history Automatic generation of information electronic health record.
5. terminal according to claim 1, is characterized in that, also comprises:
Modify instruction receiver module, for receiving modify instruction;
Information modified module, revises corresponding information for the modify instruction receiving according to described modify instruction receiver module;
Described information modified module comprises:
First revises submodule, when comprising corresponding information option when modify instruction, again indicates corresponding information option according to modify instruction;
Second revises submodule, for replacing and revise the front information option indicating according to modify instruction in the time that described modify instruction not comprising corresponding information option.
6. an input method for rescue service station structure electronic health record, is characterized in that, comprising:
Receive key word instruction, mate information list corresponding to this key word instruction according to the key word instruction of described reception, described information list comprises multiple information options;
Receive information option instruction, indicate corresponding information option according to the information option instruction receiving;
Automatically generate electronic health record according to the information option of described sign;
Preserve the electronic health record of described automatic generation;
The electronic health record of described preservation is uploaded onto the server.
7. method according to claim 6, is characterized in that, before the instruction of described reception key word, also comprises:
Build information list corresponding to all key word instructions, wherein, a corresponding information list of key word instruction.
8. method according to claim 6, is characterized in that, described automatically generate electronic health record according to the information option of described sign before, also comprise:
Whether the key word instruction that judgement has received comprises all key words, if so, automatically generates electronic health record according to the information option of described sign, otherwise continues to receive key word instruction.
9. method according to claim 6, is characterized in that, also comprises:
Receive the sick instruction of planting, mate disease kind template corresponding to this disease kind instruction according to the disease kind instruction of described reception, described sick kind in template comprises main suit, present illness history and important previous history information;
According to the main suit in the disease kind template of described coupling, present illness history and important previous history Automatic generation of information electronic health record.
10. method according to claim 6, is characterized in that, before the described electronic health record by preservation uploads onto the server, also comprises:
Receive modify instruction;
Revise corresponding information according to the modify instruction of described reception;
The described modify instruction according to described reception is revised corresponding information and is comprised:
Again the information option that beacon information option or replacement indicate before revising, in the time that modify instruction comprises corresponding information option, indicates corresponding information option again according to modify instruction, otherwise, replace the information option indicating before modification according to modify instruction.
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| CN201210401812.8A CN103778311A (en) | 2012-10-19 | 2012-10-19 | Entry terminal and method for first-aid workstation structured electronic medical records |
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| CN201210401812.8A CN103778311A (en) | 2012-10-19 | 2012-10-19 | Entry terminal and method for first-aid workstation structured electronic medical records |
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| CN105447299A (en) * | 2014-09-19 | 2016-03-30 | 余仪呈 | System and method for self-help inquiry and generation of structured complaint medical records |
| CN106845943A (en) * | 2017-02-06 | 2017-06-13 | 徐艳艳 | Medicine（Including medicine equipment）Registration management system |
| CN106845059A (en) * | 2015-12-04 | 2017-06-13 | 北大医疗信息技术有限公司 | Case history input device and case history input method |
| CN107038336A (en) * | 2017-03-21 | 2017-08-11 | 科大讯飞股份有限公司 | A kind of electronic health record automatic generation method and device |
| CN107894870A (en) * | 2017-12-04 | 2018-04-10 | 百和医疗科技（深圳）有限公司 | Monitor the mobile terminal and its system of first aid procedure |
| CN107919163A (en) * | 2017-12-04 | 2018-04-17 | 百和医疗科技（深圳）有限公司 | Monitor the mobile terminal and its system of first aid procedure |
| CN108021330A (en) * | 2017-12-04 | 2018-05-11 | 百和医疗科技（深圳）有限公司 | The system for recording the mobile terminal of first aid procedure time and monitoring first aid procedure |
| CN108962341A (en) * | 2017-05-26 | 2018-12-07 | 中国医学科学院北京协和医院 | A kind of method, apparatus and Medical Devices of record rescue process event |
| CN109378077A (en) * | 2018-08-13 | 2019-02-22 | 北京康夫子科技有限公司 | The machine readable storage medium of history-taking method and execution this method before examining |
| CN111180023A (en) * | 2018-11-09 | 2020-05-19 | 上海依智医疗技术有限公司 | Method and device for generating medical record |
| CN112925876A (en) * | 2019-12-05 | 2021-06-08 | 金色熊猫有限公司 | Method, device, medium and equipment for processing cross-site migration structured medical records |
| CN113241185A (en) * | 2021-05-20 | 2021-08-10 | 东华医为科技有限公司 | Method for generating medical text fragment of patient |
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| CN111180023A (en) * | 2018-11-09 | 2020-05-19 | 上海依智医疗技术有限公司 | Method and device for generating medical record |
| CN112925876A (en) * | 2019-12-05 | 2021-06-08 | 金色熊猫有限公司 | Method, device, medium and equipment for processing cross-site migration structured medical records |
| CN112925876B (en) * | 2019-12-05 | 2023-11-10 | 金色熊猫有限公司 | Method, device, medium and equipment for processing structured medical record migrated across sites |
| CN113241185A (en) * | 2021-05-20 | 2021-08-10 | 东华医为科技有限公司 | Method for generating medical text fragment of patient |
| CN113241185B (en) * | 2021-05-20 | 2024-04-02 | 东华医为科技有限公司 | Method for generating medical text fragments of patient |
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Application publication date: 20140507 |