阅读说明：本技术 一种用于病历质控的智能数据监控系统和方法 (Intelligent data monitoring system and method for medical record quality control ) 是由 周海龙 张华鹤 吴强 厉海洋 朱晓玲 钱丽静 金莉莎 于 2019-09-29 设计创作，主要内容包括：本发明为一种用于病历质控的智能数据监控系统和方法,提供了一种智能数据监控系统及方法。智能数据监控系统可包括用于对病历进行自动排查的自动排查模块,以及用于在日间对病历进行自动排查的日间自动排查模块。自动排查模块可包括汇总查询模块,用于对汇总查询时间段内的病历进行汇总查询,以获得所述汇总查询时间段内的科室完成情况和/或医师个人完成情况,和/或在所述汇总查询时间段内的一时间节点有未完成病历时转到科室查询模块以查询未完成病历；和/或科室查询模块,用于根据病历相关信息,对科室查询时间段内的科室病历进行科室查询以获得所述科室的医师个人完成情况,和/或查询科室查询时间段内的未完成病历,和/或查询所述汇总查询时间段内的该时间节点的未完成病历。(The invention provides an intelligent data monitoring system and method for quality control of medical records. The intelligent data monitoring system can include an automatic review module for automatically reviewing medical records and an automatic daytime review module for automatically reviewing medical records during the daytime. The automatic investigation module can comprise a summary query module which is used for summarizing and querying medical records in the summary query time period to obtain department completion conditions and/or doctor individual completion conditions in the summary query time period, and/or transferring the medical records to the department query module to query incomplete medical records when a time node in the summary query time period has incomplete medical records; and/or the department query module is used for carrying out department query on department medical records in the department query time period according to the medical record related information so as to obtain the personal completion condition of doctors in the department, and/or querying incomplete medical records in the department query time period, and/or querying incomplete medical records of the time node in the summary query time period.)

1. An intelligent data monitoring system is characterized by comprising an automatic examination module for automatically examining medical records and an automatic day examination module for automatically examining the medical records in the day.

2. The intelligent data monitoring system according to claim 1, wherein the automatic troubleshooting module comprises a summary query module configured to perform a summary query on medical records in a summary query time period to obtain department completion and/or physician individual completion in the summary query time period, and/or forward a time node in the summary query time period having an incomplete medical record to a department query module to query the incomplete medical records; and/or a department query module, configured to perform department query on department medical records in a department query time period according to medical record related information to obtain a physician individual completion condition of the department, and/or query incomplete medical records in the department query time period, and/or query incomplete medical records of the time node in the summarized query time period.

3. The intelligent data monitoring system according to claim 1 or 2, wherein the summary query time period and/or department query time period is selected by any one of year, season, month, day; and/or the medical record related information can include one or more of a medical record number, department, physician name, patient name, physician job number; and/or the automatic troubleshooting module and/or the daytime automatic troubleshooting module are also used for summarizing the troubleshooting results.

4. The intelligent data monitoring system according to claim 1 or 2, wherein the daytime automatic examination module is used for performing daytime automatic examination on the examined medical records passing through the automatic examination module to perform medical record completion examination, and feeding the daytime examination results to the automatic examination module; and/or the daytime automatic troubleshooting module periodically and/or aperiodically performs daytime troubleshooting; and/or the day automatic checking module checks the day according to a period of checking once every four hours.

5. The intelligent data monitoring system according to claim 1 or 2, further comprising a troubleshooting passing module for sending a notification of the troubleshooting passing of the automatic troubleshooting module to the daytime automatic troubleshooting module and/or notifying a medical record of the troubleshooting passing through the automatic troubleshooting module to the daytime automatic troubleshooting module; and/or a notification rectification module for sending rectification notification to the relevant doctor/department with problems; and/or a checking and correcting condition module, which is used for checking and correcting relevant doctors/departments and the like; and/or a doctor training/learning module for training/learning the relevant doctor/department; and/or the normative medical record generation module is used for generating normative medical records and transmitting the normative medical records to the hospital information system electronic medical record input module.

6. A method for automatically reviewing medical records, comprising:

summarizing and querying to summarize medical records in a summarizing and querying time period so as to obtain department completion conditions and/or doctor individual completion conditions in the summarizing and querying time period, and/or forwarding the medical records to a department for querying when incomplete medical records exist at a time node in the summarizing and querying time period; and/or

And inquiring departments, namely performing department inquiry on department medical records in a department inquiry time period according to the medical record related information to obtain the personal completion condition of doctors in the departments, and/or inquiring uncompleted medical records in the department inquiry time period, and/or inquiring uncompleted medical records of the time nodes in the summary inquiry time period.

7. The method of claim 6, further comprising automatically reviewing medical records during the daytime, wherein the summary query period and/or department query period is selected by any of year, season, month, day; and/or summarizing the results of the automatic investigation; and/or the medical record related information can include one or more of a medical record number, department, physician name, patient name, physician job number.

8. The method according to claim 6 or 7, wherein the automated daily review comprises performing an automated daily review of the reviewed medical records passing through the automated review module to perform a medical record completion review; and/or the daytime automatic troubleshooting is performed periodically and/or aperiodically; and/or the daytime automatic investigation is carried out according to a period of once every four hours.

9. The method according to claim 6 or 7, further comprising sending a notification through automatic review and/or a medical record through the automatic review for the daytime automatic review; and/or sending an alert of the correction to the relevant doctor/department with the problem; and/or to have the relevant doctor/department, etc. perform examination and modification; and/or training/learning the relevant doctor/department; and/or generating a normative medical record to enter the electronic medical record of the hospital information system.

Technical Field

The invention relates to the field of intelligent monitoring, in particular to an intelligent data monitoring system and method for quality control of medical records.

Background

According to the existing diagnosis and treatment specifications and the medical record quality control requirements, the control on the content quality of the medical record is not manually controlled, and the requirement of fine management cannot be realized. Because the medical record quality control management and control nodes are many, the prior art is difficult to manage and control each department and each doctor to each medical record, and the whole process traceability is difficult to realize, so the medical record informatization management level and the medical record supervision efficiency and quality in the prior art are lower.

Disclosure of Invention

The invention aims to provide an intelligent data monitoring system and method for quality control of medical records.

According to one aspect of the invention, an intelligent data monitoring system is provided, comprising an automatic troubleshooting module for automatically troubleshooting medical records, and an automatic daytime troubleshooting module for automatically troubleshooting medical records during the daytime.

According to the intelligent data monitoring system of the above aspect of the present invention, the automatic troubleshooting module includes a summary query module, configured to perform summary query on medical records in a summary query time period to obtain department completion conditions and/or physician individual completion conditions in the summary query time period, and/or forward a time period in which there is an incomplete medical record at a time node in the summary query time period to the department query module to query the incomplete medical record; and/or a department query module, configured to perform department query on department medical records in a department query time period according to medical record related information to obtain a physician individual completion condition of the department, and/or query incomplete medical records in the department query time period, and/or query incomplete medical records of the time node in the summarized query time period.

The intelligent data monitoring system according to the above aspect of the present invention, wherein the summary query period and/or the department query period is selected by any one of year, season, month, and day; and/or the medical record related information can include one or more of a medical record number, department, physician name, patient name, physician job number; and/or the automatic troubleshooting module and/or the daytime automatic troubleshooting module are also used for summarizing the troubleshooting results.

According to the intelligent data monitoring system of the above aspect of the invention, the automatic daytime checking module is used for automatically checking the medical records checked by the automatic checking module in the daytime so as to complete checking of the medical records, and feeding the checking result in the daytime to the automatic checking module; and/or the daytime automatic troubleshooting module periodically and/or aperiodically performs daytime troubleshooting; and/or the day automatic checking module checks the day according to a period of checking once every four hours.

The intelligent data monitoring system according to the aspect of the invention further comprises a troubleshooting passing module, which is used for sending the notification that the automatic troubleshooting module has passed the troubleshooting to the daytime automatic troubleshooting module and/or notifying the daytime automatic troubleshooting module of the medical history of the troubleshooting which passes the automatic troubleshooting module; and/or a notification rectification module for sending rectification notification to the relevant doctor/department with problems; and/or a checking and correcting condition module, which is used for enabling relevant doctors/departments and the like to check and correct; and/or a doctor training/learning module for training/learning the relevant doctor/department; and/or the normative medical record generation module is used for generating normative medical records and transmitting the normative medical records to the hospital information system electronic medical record input module.

According to another aspect of the invention, a method for automatically checking medical records is provided, which includes summarizing and querying medical records in a summarized and queried time period to obtain department completion and/or physician individual completion in the summarized and queried time period, and/or forwarding incomplete medical records to department for querying when a time node in the summarized and queried time period has incomplete medical records; and/or department query, according to the medical record related information, performing department query on the department medical records in the department query time period to obtain the personal completion condition of doctors in the department, and/or querying incomplete medical records in the department query time period, and/or querying incomplete medical records of the time node in the summary query time period.

The method according to the above aspect of the present invention further comprises automatically reviewing medical records during the daytime, wherein the summary query period and/or the department query period are selected by any one of year, season, month, and day; and/or summarizing the results of the automatic investigation; and/or the medical record related information can include one or more of a medical record number, department, physician name, patient name, physician job number.

The method according to the above aspect of the present invention, wherein the daytime automatic review includes performing daytime automatic review on the reviewed medical records that pass through the automatic review module to perform medical record completion check; and/or the daytime automatic troubleshooting is performed periodically and/or aperiodically; and/or the daytime automatic investigation is carried out according to a period of once every four hours.

The method according to the above aspect of the present invention further comprises sending a notification through automatic investigation and/or a medical record through the automatic investigation to perform the daytime automatic investigation; and/or sending an alert of the correction to the relevant doctor/department with the problem; and/or to have the relevant doctor/department, etc. perform examination and modification; and/or training/learning the relevant doctor/department; and/or generating a normative medical record to enter the electronic medical record of the hospital information system.

According to the above aspects of the present invention, as described above, the intelligent data monitoring system and method of the present invention conform to various diagnosis and treatment specifications and/or medical record quality control requirements, such as "quality control standards for medical records in shanghai district 2015 edition", "quality assessment and evaluation standards for medical records in shanghai district 2015 edition", "basic writing specifications for medical records (2010 edition), and/or" writing quality 24 assessment indexes for medical records in shanghai city (trial edition), but the present invention is not limited thereto. The invention tightly links the key medical record management and control time nodes, automatically inquires and extracts the management and control data, automatically checks the operating medical records which are not completed in the time efficiency, generates a report, and automatically counts the medical record quality control key time management and control nodes which are not completed according to the specified time limit, thereby combining the macro and micro functions, realizing the real-time automatic management and control of selected indexes of all medical records, managing and controlling the medical records to departments, managing and controlling doctors, managing and controlling each medical record, realizing the whole-process traceability, facilitating the self management and control of the departments, improving the informatization management level of the medical records, and improving the monitoring efficiency and quality of the medical records. For example, the functional department can query the operation condition of main management and control indexes of medical record operation of all medical institutions in real time, and can also query departments, doctors and each medical record; the department can also inquire whether the main management and control indexes of the department operating medical record are finished on time or not in real time through authorization, and the operation conditions, the individual doctors and the corresponding medical record; the doctor can also inquire the operation condition of the main management and control index of the operation medical record of the doctor and the corresponding medical record in real time through the invention, thereby being convenient for managing and controlling the quality of the medical record in real time. In addition, the defects of the patient can be found through inquiry, and the medical record management and control quality is improved conveniently. Because the related management station accounts can be realized electronically, further statistical analysis is facilitated.

In addition, the invention can also meet the requirement of index management of medical quality by the national medical council, is convenient for information collection, statistics, analysis, comparison and feedback of medical record management conditions of each medical institution, carries out scientific, reasonable and fair evaluation on the medical record quality of each medical institution, and promotes the management of the medical record quality of each medical institution.

The invention has diversified query modes, and can query through related information of various medical records, and the like, thereby facilitating the query of users. The invention can provide statistical reports according to the year, season and month, is convenient for various examinations, publicity and management, and realizes informatization, automation, intellectualization and fine management of medical records. The invention can display the completion percentage of departments through direct summarization, and can see a specific physician when the departments are opened, so as to inquire the medical record and finally determine the quality control loop node of the medical record. The time management and control of the invention takes the patient entering time as a basic point, so that the system can be brought into statistics when the time is up, and the data quality is guaranteed. Because the invention adopts automatic investigation and/or automatic investigation during the daytime, the examination such as the timeliness rate of case completion can be automated, and because the medical record is periodically examined every day during the daytime, the examination of the complete coverage can be realized, the invention is very convenient, the medical record and the doctor with problems can be pointed and prompted, and the telephone communication is used for supervising and improving, thereby reducing the workload of the manual first-time examination, and the invention can directly carry out precise quality control and improve the education work. In addition, according to the invention, a management department can master automatic inspection information, randomly extract and monitor the integrity and the logicality of the writing content of each medical record data and the time limit of medical record completion in real time, thereby realizing beforehand reminding, in-process supervision and after-process assessment, converting the final quality control of the traditional medical records into link quality control and improving the medical quality and management. The information of automatic examination can be opened to each department master and doctor, which is convenient for self examination and improvement.

Furthermore, the data acquisition according to the invention can use the Extract-Transform-load (etl) technology of the big data independent of the data interface processing mode of the Hospital Information System (HIS) system, thereby building a big data hardware service architecture in the hospital intranet, supporting the infinite expansion configuration cluster mode, and realizing the automatic extraction, transformation and display of the used data.

Drawings

FIG. 1 schematically illustrates one example of an intelligent data monitoring system architecture in accordance with one embodiment of the present invention.

Fig. 2 schematically shows a flow chart of an example of a method according to an embodiment of the invention.

Fig. 3 schematically shows a flow chart of an example of a method according to an embodiment of the invention.

Detailed Description

In order to make the objects, technical solutions and advantages of the present invention more apparent, the present invention is described in further detail below with reference to the accompanying drawings and embodiments. It should be understood that the specific embodiments described herein are merely illustrative of the invention and are not intended to limit the invention.

Although the following description sets forth various implementations that may be shown, for example, in a system architecture, implementations of the techniques and/or arrangements described herein are not limited to a particular system architecture and/or computing system and may be implemented by any architecture and/or computing system for similar purposes. For example, various architectures and/or various computing devices and/or electronic devices employing, for example, one or more integrated circuit chips and/or packages, may implement the techniques and/or arrangements described herein. Furthermore, although the following description may set forth numerous specific details (e.g., logical implementations, types and interrelationships of system components, logical partitioning/integration choices, etc.), claimed subject matter may be practiced without these specific details. In other instances, some materials (e.g., control structures and complete software instruction sequences) may not be shown in detail in order not to obscure the material disclosed herein. The materials disclosed herein may be implemented in hardware, firmware, software, or any combination thereof.

The materials disclosed herein may also be implemented as instructions stored on a machine-readable medium or memory that may be read and executed by one or more processors. A computer-readable medium may include any medium and/or mechanism for storing or transmitting information in a form readable by a machine (e.g., a computing device). For example, a machine-readable medium may include Read Only Memory (ROM), Random Access Memory (RAM), magnetic disk storage media; an optical storage medium; a flash memory device; and/or other media. In another form, a non-transitory article (e.g., a non-transitory computer readable medium) can be used for any of the above-mentioned examples or other examples, including such elements (e.g., RAM, etc.) that can temporarily store data in a "transient" manner.

FIG. 1 illustrates one example of an architecture of an intelligent data monitoring system 100 in accordance with one embodiment of the present invention. As shown in fig. 1, the intelligent data monitoring system 100 can be used for performing informatization collection, statistics, analysis, comparison and feedback on the medical record management conditions of each medical institution, and performing scientific, reasonable and fair evaluation on the quality of the medical records of each medical institution, thereby promoting the management of the medical record quality of each medical institution.

In one embodiment, according to the requirements of the existing basic medical record writing specifications (2010 version), the quality control center of medical record quality management in Shanghai city formulates a series of assessment indexes for quality control of medical records. The key management and control indexes of the medical record selected by the invention can comprise: the first course record is completed within 8 hours after the patient is admitted, the admission record is completed within 24 hours, the ward visit of the treating physician is completed within 48 hours, the first visit record of the chief (assistant chief) physician is completed within 1 week, the record is completed within 24 hours after the operation record, the relevant examination before blood transfusion is lacked in the blood transfusion medical record, the record of death is completed within 24 hours after the patient dies, the pre-operation discussion record of the middle (third) stage or above selective operation, the record of the course of the chief (assistant chief) physician who has critical to have a disease continuously for 3 days, and/or the stage nodules are once every 31 days, and the like. However, in other embodiments, the invention is not limited to the key management and control indexes of the medical records, but can implement real-time automatic management and control of other related indexes according to writing basic specifications, diagnosis and treatment specifications and/or quality control requirements of the medical records.

As shown in FIG. 1, the system 100 can include a HIS electronic medical record entry module 102. The HIS electronic medical record entry module 102 can be used to store various medical record related information, such as, but not limited to, a medical record number, a department, a physician name, a physician job number, a patient name, a medical record, a procedure condition (e.g., a procedure code, a procedure name, unplanned procedure information, daytime procedure information, a physician name, a physician job number, a 1-physician assistant, a 2-physician assistant, procedure/reoperation information, procedure related examination items), and the like. In another embodiment, the HIS electronic medical record entry module 102 can be a module external to the system 100, but the invention is not so limited.

In one embodiment, the system 100 can realize functional department query and/or department query, and doctors can also perform personal query through department passwords, so as to manage the quality of medical records in real time. For example, the functional department can query the operation condition of one or more items in the medical record management and control indexes of the operating medical records of the whole hospital in real time, and can query the department, the personnel of a doctor and each medical record. The department can inquire the operation condition of one or more items in the medical record management and control indexes of the medical record operated in the department in real time, and can also inquire the individual and each medical record of a doctor.

As shown in FIG. 1, the system 100 can include an electronic medical record extraction module 104 for extracting electronic medical records from the HIS electronic medical record entry module 102 and transmitting the electronic medical records to an automated review module 106 and/or an automated daily review module 108 for automated review. In one embodiment, the system 100 can implement a plurality of query methods, for example, the medical record can be queried through one or more of the medical record related information such as the medical record number, department, physician name, patient name, physician employee number, etc., so as to facilitate the query of the user. In one embodiment, the electronic medical record extraction module 104 can extract an electronic proportion corresponding to one or more of the relevant information of medical records from the HIS electronic medical record entry module 102 based on one or more of the relevant information of medical records, such as medical record number, department, physician name, patient name, physician employee number, etc., and transmit the electronic proportion to the automatic review module 106 and/or the automatic review module 108.

In one embodiment, the automatic review module 106 may include a summary query module (not shown) and/or a department query module (not shown). Referring to fig. 1 and 2, the summary query module can be used to perform summary queries (e.g., query all medical records corresponding to a selected time period) for a selected time period of year, season, month, day, or other time period, directly leave a corresponding department when a certain time node is found to have an incomplete medical record, find a medical doctor (e.g., refer to the flow illustrated in fig. 2, but the present invention is not limited thereto), and then go to a department query module (not shown) to query which medical record is incomplete or unmanaged at the time node (e.g., refer to the flow illustrated in fig. 3, but the present invention is not limited thereto).

In another embodiment, the query may be performed directly using a department query module. For example, the department query module can be configured to perform the required query at the selected time period through one or more of the medical record number, department, physician name, patient name, and/or physician job number or other medical record related information, so as to directly find the incomplete medical record and/or the unregulated time node, etc. (e.g., refer to the flow shown in fig. 3, but the invention is not limited thereto).

As shown in fig. 1, the system 100 can further include an automatic daily review module 108 for performing automatic daily review on the reviewed medical records passed through the automatic review module 106 to automatically review the completion timeliness and the like of the medical records, and can feed the review results to the automatic review module 106. Although not shown in FIG. 1, in another embodiment, the daytime automatic review module 108 may also be coupled to the review pass module 112 and/or the suspected problems module 114, although the invention is not limited thereto. In yet another embodiment, the associated management ledger can be implemented electronically to facilitate further statistical analysis. In one embodiment, the daytime automated review module 108 may include a summary query module and/or a department query module similar to the automated review module 106, although the invention is not limited thereto.

In one embodiment, the daytime automatic review module 108 may perform periodic review, for example, one or more of the medical record related review items may be reviewed every 4 hours during the daytime, respectively 8 am, 12 pm, 4 pm, and/or 8 pm, thereby achieving full coverage of review of medical record related items such as time rate review and/or writing of medical records. In other embodiments, the daytime automatic review module 108 may review at other periods or may perform aperiodic reviews, although the invention is not limited in this respect.

In one embodiment, the automatic review module 106 and/or the daytime automatic review module 108 may also be used to aggregate the review results. For example, the query time range of the automatic checking module 106 and/or the automatic checking module 108 may be provided with a summary report for statistics, assessment, publicity and management according to year, season, month, day or other time periods, and may also be used for department quality assessment, so as to implement informatization, automation, intellectualization and refinement management of medical records, but the present invention is not limited thereto. The automatic review module 106 and/or the daytime automatic review module 108 may summarize the review results to display the percentage of completed and/or incomplete departments, and then the departments may be started to see the specific physician, and then the medical records of the physician may be queried to finally determine the medical record quality control ring nodes, but the invention is not limited thereto. In yet another embodiment, the query results of the automated review module 106 and/or the daytime automated review module 108 may be completed, incomplete, and/or not occurred according to different displays of medical records, but the invention is not limited thereto.

In one embodiment, the automated review module 106 and/or the daytime automated review module 108 may automatically review and/or manage one or more of the patient record management metrics, although the invention is not limited in this respect. By providing a login module for login and account management of each department, the system can log in by inputting a password for automatic examination, but the invention is not limited thereto. In yet another embodiment, the query may be divided into a functional department query and/or a department query, and the physician person may also perform the personal query by the department password. In yet another embodiment, the associated management ledgers can be implemented electronically to facilitate further statistical analysis.

As shown in FIG. 1, the system 100 also includes a troubleshooting pass module 112. In one embodiment, the review pass module 112 is coupled to the daytime automatic review module 108 for notifying the daytime automatic review module 108 of the medical record passed by the review by the automatic review module 106 to cause the daytime automatic review module 108 to perform daytime automatic review. If the automatic troubleshooting module 106 fails the check, the suspected problem module 114 may be used to generate a suspected problem for manual confirmation (120). After the problem is manually confirmed, an rectification notification can be sent to the relevant doctor/department, etc. having the problem via the rectification notification module 122, so that the relevant doctor/department, etc. can perform the examination rectification through the examination rectification condition module 124 and perform the training/learning through the doctor training/learning module 126, and/or can generate a normative medical record through the normative medical record generating module 128 and transmit the normative medical record to the HIS electronic medical record entry module 102. In another embodiment, the system 100 may not include one or more of the rectification notification module 124, the examination rectification module 124, the physician training/learning module 126, and/or the normative medical record generation module 128, although the invention is not limited thereto. For example, the system can pointedly prompt the case history and doctors with problems and supervise and urge improvement through telephone communication, thereby directly carrying out accurate quality control and improving the education work.

In one embodiment, the quality control manager can randomly extract and/or monitor the integrity, logicality, and/or time limit of medical record completion of each medical record via the system 100 (e.g., the automatic review module 106 and/or the daytime automatic review module 108), so as to realize advance warning, in-process supervision, and post-process assessment, thereby improving medical quality. Besides being mastered by the management department, the examination can also open the information automatically examined by the system to each department master and/or doctor for self-examination and improvement. In one embodiment, the medical record real-time monitoring can be performed from a monitoring subject, a monitoring mode and/or a monitoring time.

In one embodiment, the monitoring subject of the system 100 may include content monitoring, time limit monitoring, and/or process monitoring, among others. For example, a quality monitoring system can be established for medical record control indexes such as hospitalization records, first disease course records, ward visit time of an attending physician, operation records, relevant examinations before blood transfusion lack in a blood transfusion medical record, death record completion time and the like, but the invention is not limited thereto.

In another embodiment, the monitoring mode of the system 100 may include automatic monitoring and/or manual monitoring. For example, the system 100 may establish an automatic monitoring system by monitoring time points such as a content table, admission time, and medical order time, and timely remind a doctor of content and time limit required to be completed; the quality control manager can randomly check the medical records through the system 100, manually monitor the quality of the medical records, fill in incomplete or out-of-time medical record records, and remind doctors in time, but the invention is not limited thereto.

In yet another embodiment, the monitoring time of the system 100 may include a prior reminder, an in-process supervision, and/or a post assessment. For example, by using the electronic medical record, the automatic review module 106 and/or the daytime automatic review module 108 can be used to convert the post-affair supervision of the quality of the traditional medical record into pre-reminding, in-affair supervision and post-affair supervision, and convert the final quality control of the traditional medical record into link quality control, thereby improving the management level, but the invention is not limited thereto. In one embodiment, the time management of the system 100 may be based on the time of patient entering the area, and the system 100 may incorporate statistics when the time is not completed, thereby ensuring data quality, but the invention is not limited thereto.

In one embodiment, the system 100 (e.g., the auto-troubleshooting module 106 and/or the daytime auto-troubleshooting module 108) may perform time limit monitoring. For example, the system 100 may employ a comparison criterion to count the number and/or completion time of medical records written and reviewed by a physician over a certain period of time, and differentiate the monitoring time limit according to the relationship existing between medical documents, but the invention is not limited thereto.

In another embodiment, the system (e.g., the automatic review module 106 and/or the daytime automatic review module 108) may also perform content monitoring. The medical record writing content monitoring is an important basis for reflecting whether medical record writing items are complete or not. In one embodiment, the automatic review module 106 and/or the daytime automatic review module 108 may be used only to automatically monitor the presence or absence of a prescribed written item to alert the physician of which records should be made in this manner, and how the content of the medical record is written may be evaluated manually by, for example, an expert, although the invention is not limited in this respect.

In yet another embodiment, the monitoring system 100 may include physician orders and/or medical records, although the invention is not limited thereto.

In yet another embodiment, the content monitoring philosophy of the system 100 may include, for example, content monitoring of patients that do not include hospital exams and/or hospital admissions and discharges within 24 hours; when writing the disease course record, selecting the corresponding item provided by the guide bar to write by adopting a number-matching seating mode, otherwise, monitoring is not accurate; and/or monitoring only the first disease course record, admission record, ward visit of a treating doctor, the first ward visit of a chief (assistant chief deputy) doctor and/or death record of a patient who is hospitalized for less than or equal to 7 days, monitoring statistics such as preoperative discussion record, operation record completion time and the like of postoperative (tertiary) elective surgery for the operation patient, and/or monitoring statistics such as related examination before blood transfusion for the blood transfusion patient. For example, the automatic review module 106 and/or the daytime automatic review module 108 may monitor according to one or more of the content monitoring principles, but the invention is not limited to the monitoring principles, and may be based on various medical record writing specifications, medical record specification and/or medical record quality control requirements, etc.

FIG. 1 illustrates only one example of an intelligent data monitoring system in accordance with one embodiment of the invention, and in other embodiments, the intelligent data monitoring system 100 may include one or more of the modules illustrated in FIG. 1. In yet another embodiment, the intelligent data monitoring system 100 may be implemented using software, hardware, firmware, and/or various combinations thereof.

Fig. 2 schematically shows a flow chart of an example of a method according to an embodiment of the invention. In one embodiment, the method can be used for monitoring medical records, and the completion timeliness rate of the medical records can be found through summary query, so that the management and control quality of the medical records can be improved. In one embodiment, the system 100 in FIG. 1 (e.g., the automated review module 106 and/or the daytime automated review module 108) can utilize the methods to perform automated review to manage medical record quality in real-time. According to one aspect of the invention, the method can be used to implement full coverage management of medical records and automatic timely review and/or automatic review of writing-related items of medical records or other review.

As shown in fig. 2, at block 202, the intelligent management system may be logged in for account management (block 204) and/or entered into the aggregation module (block 206) for troubleshooting via a login account number and password assigned to each department, etc.

Referring to FIG. 2, in response to entering the summarization module, the queries may be summarized (block 210) corresponding to the query time entered at block 208. For example, the aggregated query time range may be by year, season, month, day, or other time period. For example, at block 210, all medical records within the entered time period may be queried to obtain department completion at block 212 and/or physician personal completion at block 214. In another embodiment, although not shown in fig. 2, the method further includes directly opening a corresponding department to find a principal if a certain time node is found to be incomplete in the aggregated query of block 210, and then conducting a department query to find incomplete and/or unmanaged medical records of the time node or other queries according to a flow such as that shown in fig. 3, but the invention is not limited thereto. In another embodiment, the department query can be directly performed according to the flow described in fig. 3, and incomplete and/or unregulated medical records and the like can be performed at the time node or other queries can be performed.

Fig. 2 shows only an example of a method according to an embodiment of the present invention, but the present invention is not limited thereto. Although not shown in fig. 2, in one embodiment, the method further comprises summarizing the examination results such as department completion and/or individual completion, and presenting a summary report for statistics and public use, and may also be used for department quality assessment and performance assessment. The related management station accounts can also be electronized, so that further statistical analysis is facilitated. Although not shown in FIG. 2, in another embodiment, the method may further include sending an alert of the rectification to the relevant doctor/department with the problem; and/or to have the relevant doctor/department, etc. perform examination and modification; and/or training/learning the relevant doctor/department; and/or generating and transmitting normative medical records for HIS electronic medical record entry, although the invention is not so limited.

Fig. 3 schematically shows a flow chart of an example of a method according to an embodiment of the invention. In one embodiment, the method can be used for monitoring medical records, and the completion timeliness rate of the medical records can be found through department query, so that the management and control quality of the medical records can be improved. In one embodiment, the system 100 in FIG. 1 (e.g., the automated review module 106 and/or the daytime automated review module 108) can utilize the methods to perform automated review to manage medical record quality in real-time. According to one aspect of the invention, the method can be used to implement full coverage management of medical records and automatic timely review and/or automatic review of writing-related items of medical records or other review.

As shown in fig. 3, at block 302, the intelligent management system may be logged in via a login account number and password assigned to each department for account management (block 304) and/or access to department modules (block 306) for troubleshooting.

Referring to FIG. 3, in response to entering the department module, a query time may be entered at block 308. For example, the query time range may be by year, season, month, day, or other time period. At block 310, one or more of the medical record number, department, physician name, patient name, and/or physician job number and/or other medical record related information may be entered to perform the desired department query. For example, the department query can include a review of medical records corresponding to the query time range and the medical record related information. At block 312, the physician's personal completion corresponding to the entered query time (block 308) and the entered medical record-related information (block 310) can be obtained to find incomplete medical records and/or unmanaged medical records at that time node or to perform other queries.

Fig. 3 shows only an example of a method according to an embodiment of the present invention, but the present invention is not limited thereto. Although not shown in fig. 3, in one embodiment, the method further comprises summarizing the examination results such as the completion of the individual, presenting a summary report for statistics and public use, and also for department quality assessment and performance assessment. The related management station accounts can also be electronized, so that further statistical analysis is facilitated. Although not shown in FIG. 3, in another embodiment, the method may further include sending an alert of the rectification to the relevant doctor/department with the problem; and/or to have the relevant doctor/department, etc. perform examination and modification; and/or training/learning the relevant doctor/department; and/or generating and transmitting normative medical records for HIS electronic medical record entry, although the invention is not so limited.

As described above, the intelligent data monitoring system and method of the present invention conform to various medical treatment specifications and/or medical record quality control requirements, such as "quality control standards for medical records in shanghai district 2015 edition", "quality assessment and evaluation standards for medical records in shanghai district 2015 edition", "basic medical record writing specifications (2010 edition), and/or" 24 assessment indexes for medical record writing quality in shanghai city (trial edition), etc., but the present invention is not limited thereto. The invention tightly links the key medical record management and control time nodes, automatically inquires and extracts the management and control data, automatically checks the operating medical records which are not completed in the time efficiency, generates a report, and automatically counts the medical record quality control key time management and control nodes which are not completed according to the specified time limit, thereby combining the macro and micro functions, realizing the real-time automatic management and control of selected indexes of all medical records, managing and controlling the medical records to departments, managing and controlling doctors, managing and controlling each medical record, realizing the whole-process traceability, facilitating the self management and control of the departments, improving the informatization management level of the medical records, and improving the monitoring efficiency and quality of the medical records. For example, the functional department can query the operation condition of main management and control indexes of medical record operation of all medical institutions in real time, and can also query departments, doctors and each medical record; the department can also inquire whether the main management and control indexes of the department operating medical record are finished on time or not in real time through authorization, and the operation conditions, the individual doctors and the corresponding medical record; the doctor can also inquire the operation condition of the main management and control index of the operation medical record of the doctor and the corresponding medical record in real time through the invention, thereby being convenient for managing and controlling the quality of the medical record in real time. In addition, the defects of the patient can be found through inquiry, and the medical record management and control quality is improved conveniently. Because the related management station accounts can be realized electronically, further statistical analysis is facilitated.

In addition, the invention can also meet the requirement of index management of medical quality by the national medical council, is convenient for information collection, statistics, analysis, comparison and feedback of medical record management conditions of each medical institution, carries out scientific, reasonable and fair evaluation on the medical record quality of each medical institution, and promotes the management of the medical record quality of each medical institution.

The invention has diversified query modes, and can query through related information of various medical records, and the like, thereby facilitating the query of users. The invention can provide statistical reports according to the year, season and month, is convenient for various examinations, publicity and management, and realizes informatization, automation, intellectualization and fine management of medical records. The invention can display the completion percentage of departments through direct summarization, and can see a specific physician when the departments are opened, so as to inquire the medical record and finally determine the quality control loop node of the medical record. The time management and control of the invention takes the patient entering time as a basic point, so that the system can be brought into statistics when the time is up, and the data quality is guaranteed. Because the invention adopts automatic investigation and/or automatic investigation during the daytime, the examination such as the timeliness rate of case completion can be automated, and because the medical record is periodically examined every day during the daytime, the examination of the complete coverage can be realized, the invention is very convenient, the medical record and the doctor with problems can be pointed and prompted, and the telephone communication is used for supervising and improving, thereby reducing the workload of the manual first-time examination, and the invention can directly carry out precise quality control and improve the education work. In addition, according to the invention, a management department can master automatic inspection information, randomly extract and monitor the integrity and the logicality of the writing content of each medical record data and the time limit of medical record completion in real time, thereby realizing beforehand reminding, in-process supervision and after-process assessment, converting the final quality control of the traditional medical records into link quality control and improving the medical quality and management. The information of automatic examination can be opened to each department master and doctor, which is convenient for self examination and improvement.

Moreover, according to the data acquisition method, the processing mode of the HIS system data interface is not depended on, but the big data ETL technology which does not depend on the data interface can be used, so that a big data hardware service framework is built in a hospital intranet, an infinite expansion configuration cluster mode is supported, and the automatic extraction, conversion and display of the used data are realized.

The foregoing shows and describes the general principles and features of the present invention, together with the advantages thereof. It will be understood by those skilled in the art that the present invention is not limited to the embodiments described above, which are described in the specification and illustrated only to illustrate the principle of the present invention, but that various changes and modifications may be made therein without departing from the spirit and scope of the present invention, which fall within the scope of the invention as claimed.