CN103440605A - Electronic medical record system based on wireless hand-held terminal - Google Patents
Electronic medical record system based on wireless hand-held terminal Download PDFInfo
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- CN103440605A CN103440605A CN2013104093091A CN201310409309A CN103440605A CN 103440605 A CN103440605 A CN 103440605A CN 2013104093091 A CN2013104093091 A CN 2013104093091A CN 201310409309 A CN201310409309 A CN 201310409309A CN 103440605 A CN103440605 A CN 103440605A
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Abstract
The invention discloses an electronic medical record system based on a wireless hand-held terminal. The system comprises a PDA nursing terminal, a hospital management platform and an electronic medical record platform, wherein the PDA nursing terminal comprises a specialist disease nursing module and a nursing assessment module; the hospital management platform comprises a specialist nursing knowledge base for storing specialist disease information, a nursing scheme and nursing assessment information for inquiries; and the electronic medical record platform is used for generating the nursing scheme of a patient and an execution recording chart of a nursing assessment; and the PDA nursing terminal, the hospital management platform and the electronic medical record platform share data through network connection. Maintained specialist disease nursing schemes and the nursing assessment information are acquired through the PDA nursing terminal so that a nurse can be guided to carry out a nursing assessment and treatment on the patient according to the prompting information over the PDA nursing terminal at any time and at any place, the nursing cost is lowered, the data sharing of execution records can be realized in a hospital internal network, and nursing scheme execution and the nursing assessment information can be stored in an electronic structured medical record.
Description
Technical field
The present invention relates to medical care, particularly a kind of electronic medical record system based on wireless handheld terminal.
Background technology
Development along with nursing Connotation Construction and specific nursing, not only require the nurse to possess sturdy Specialty knowledge and technical capability, also nurse's time should be returned to the patient, reduces the non-nursing time.On the one hand, because the clinical position amount is large, the otherness of nurse's clinical experience, particularly for young nurse, Specialty knowledge is weaker, use the state of an illness of Specialty knowledge evaluating patient and the propaganda and education that patient carries out Specialty knowledge is short of to some extent, NN is Shortcomings aspect systematicness, integrality, continuity and accuracy.On the other hand, present nursing history record mainly obtains by main suit, observation and medical history information, and with form row papery record or electronic health record typing, the cost of NN time is longer, and the inaccurate phenomenon of NN easily occurs.
Summary of the invention
Fundamental purpose of the present invention is to overcome above-mentioned shortcoming of the prior art, proposes a kind of electronic medical record system based on wireless handheld terminal that can automatically transform generation Electronic Nursing medical history record, improve nurse job efficiency.
The present invention adopts following technical scheme:
A kind of electronic medical record system based on wireless handheld terminal, is characterized in that: comprise
The PDA nursing terminal, comprise training sickness nursing module for creating and carry out care regimen and for assessment of the nursing evaluation module of the implementation status of this care regimen;
The hospital management platform, comprising can be for the specific nursing knowledge base of training disease information, care regimen and the nursing appreciation information of inquiring about for storage;
The electronic health record platform, for the care regimen that generates patient and the executive logging figure that nurses assessment;
Connect and realize data sharing by network between this PDA nursing terminal, hospital management platform and electronic health record platform; This PDA nursing terminal accesses the specific nursing knowledge base of hospital management platform by wireless network, retrieve and show set care regimen and nurse appreciation information, carry out the operation of training sickness nursing and nursing evaluation operation as foundation, and the executive logging of care regimen and nursing evaluation operation is shared to the electronic health record platform, the electronic health record platform generates patient's care regimen and the executive logging figure of nursing assessment.
Further, described training sickness nursing module comprise show and can be for the newly-increased care regimen unit of operation, carry out the nursing content unit, complete the care regimen unit and interrupt the care regimen unit.
Further, described nursing evaluation module comprises demonstration and can supply the interpolation of operation nurse assessment unit, project evaluation unit, the rear quantification mark unit automatically of assessment and generate the assessment view unit every day.
Further, the training disease information of described specific nursing knowledge base comprises training disease name, stage schedule, effective marker, operation sign.
Further, the care regimen of described specific nursing knowledge base comprises stage schedule, nursing items and the contents of a project, a training sickness nursing scheme can be divided into a plurality of nursing stage schedules, under each nursing stage schedule, divides again a plurality of nursing items and the contents of a project.
Further, the nursing of described specific nursing knowledge base assessment comprises that the nursing evaluation item is safeguarded, nursing assessment inventory is safeguarded and nursing assessment distribution, and a disease that calls for specialized treatment nursing assessment can have a plurality of evaluation items, and each evaluation item has a plurality of sub-projects.
From the above-mentioned description of this invention, compared with prior art, the present invention has following beneficial effect:
1, take the PDA nursing terminal as support, the training sickness nursing system of diagnosis associated packets (DRGs) for leading take in introducing, and automatically be converted into the Electronic Nursing case history, improved the accuracy of quo of nursing records writing, reduce the nursing writing mistake, improve nursing quality, there is good social benefit, have a extensive future.
2, the PDA nursing terminal is directly realized pre-bed care, strengthened the responsibility system holistic Nursing, and can make nursing content directly by the electronic health record platform, generate electronic care record, reduced the NN time, greatly improved nurse's work efficiency, really nurse's time is returned to the patient, realize patient satisfaction, nurse's satisfaction, there is good social benefit.
3, provide the concrete nursing assessment content of training disease and be connected corresponding nursing intervention, especially import tabular special care evaluation item on the PDA nursing terminal, be risk factors of pressure sore for patients assessment, hazards unscheduled event assessment (falling, fall bed etc.), automatically quantize mark after each project evaluation, make the nurse can be according to evaluation structure, take nursing intervention to be nursed, avoid a complication of disease or unscheduled event, and high-risk assessment result can be changed into to the Electronic Nursing case history automatically.
The accompanying drawing explanation
Fig. 1 is the electronic medical record system schematic diagram based on wireless handheld terminal of the present invention;
The function composition module map that Fig. 2 is the PDA nursing terminal;
The function composition module map that Fig. 3 is the specific nursing knowledge base;
The nursing appreciation information example schematic that Fig. 4 is the specific nursing knowledge base;
The care regimen example schematic that Fig. 5 is the specific nursing knowledge base;
The operation example schematic that Fig. 6 is the PDA nursing terminal (care regimen execution);
The operation example schematic (non-conformance description) that Fig. 7 is the PDA nursing terminal;
The operation example schematic that Fig. 8-Figure 11 is the PDA nursing terminal (repeating care regimen and nursing assessment);
Figure 12 is that the PDA nursing terminal is nursed the rear nursing assessment generated of assessment view for example.
Embodiment
Below by embodiment, the invention will be further described.
With reference to Fig. 1, a kind of electronic medical record system based on wireless handheld terminal comprises following several part:
1, PDA nursing terminal
The PDA nursing terminal be have operation interface, can radio communication portable hand-held terminal device, it comprises training sickness nursing module for create and carry out care regimen according to patient's state of an illness and for assessment of the nursing evaluation module of the implementation status of this care regimen.
Wherein, with reference to Fig. 2 training sickness nursing module specifically comprise according to the needs of patient's state of an illness create care regimen newly-increased care regimen unit, according to the care regimen content carry out executable operations execution nursing content unit, complete the care regimen unit, interrupt the care regimen unit and under pass to the slow sick care management system in community, in carrying out the nursing content process, if patient's state of an illness changes and can increase corresponding nursing and arrange schedule and nursing intervention, and non-conformance description is registered.Complete or interrupt the nursing after, also can will under the implementation status of care regimen, pass in the slow sick care management system in community as required.
This nursing evaluation module comprises that project evaluation unit that the interpolation that the care regimen according to patient carries out nursing evaluation operation every day nurses assessment unit, each care regimen subordinate's detailed programs are assessed every day, the assessment that assessment data is carried out to statistical treatment automatically quantize afterwards the mark unit and generate the assessment text unit, and the assessment content of each assessment unit can be carried out later maintenance and renewal as required.
2, electronic health record platform
For according to operation, generate patient's care regimen and the executive logging figure of nursing assessment.
3, hospital management platform
With reference to 3, the hospital management platform comprises for storing the specific nursing knowledge base of training disease information, care regimen and nursing appreciation information, this specific nursing knowledge base is based on DRGS diagnosis associated packets the training disease is carried out to classified finishing, and formulates professional nursing flow process, care regimen, nursing estimation items etc.
Wherein, the training disease information of storage comprises training disease name, stage schedule, effective marker, operation sign etc.The care regimen of storage comprises stage schedule, nursing items and the contents of a project, a training sickness nursing scheme can be divided into a plurality of nursing stage schedules, divide again a plurality of nursing items and the contents of a project under each nursing stage schedule, as: with reference to Fig. 5, be admitted to hospital the same day, while in hospital and leave hospital etc., stage name can be according to the self-defined setting of training genius morbi, divide again a plurality of nursing items and the contents of a project under each nursing stage, and the hierarchical relationship of self-defined content item as required, " ## " represents the most top classification.
The nursing assessment of storage comprises the maintenance of nursing evaluation item, nursing assessment inventory safeguards and distribution etc. is assessed in nursing.The nursing evaluation item safeguards that be nursing evaluation item template safeguards, comprises the following data of collecting, subject data: i.e. patient's main suit comprises the description of that patient feels, that experience and that see, content that hear, that expect etc.Objective materials: the nurse is through observation, health check-up, the patient health data that obtains by other inspect by instrument or laboratory examination etc.By above-mentioned data typing specific nursing knowledge base, a disease that calls for specialized treatment nursing assessment comprises a plurality of projects, and each project comprises respectively a plurality of options, and each option can arrange specific score value.Factors assessment data as dangerous as Fig. 4 pressure sore.
Can carry out data sharing and communicate by letter by the hospital internal network between PDA nursing terminal of the present invention, electronic health record platform and hospital management platform.Below illustrate principle of work of the present invention:
1, the execution of care regimen
The nurse carries the PDA nursing terminal, whenever and wherever possible by the wireless network access hospital management platform of hospital internal, call the specific nursing knowledge base according to patient's the state of an illness, retrieve set training disease information, care regimen and nursing appreciation information, and the care regimen execution Related Nursing according to set shown according to terminal operates, and be recorded on the PDA nursing terminal, as because partly cause, can not carry out by set care regimen, can select " not carrying out ", the reason that system can require record not carry out, make nursing have evidence, can review.As Fig. 6, Fig. 7.
2, the execution of nursing assessment
The nursing evaluation module of PDA nursing terminal adopts the combobox design, shows that nursing assessment, the project evaluation, assessment every day automatically quantizes afterwards mark and generate assessment text etc., facilitates the nurse to be nursed the assessment result registration.
3, PDA is for repeating care regimen and nursing assessment every day
The nurse, according to patient's situation, is copied care regimen, nursing assessment, and is shown with " [date] [project name] " format, as Fig. 8, Fig. 9, Figure 10, Figure 11, and records respectively operating result, reaches the purpose that special disease is repeatedly nursed execution.
4, data sharing with synchronize
PDA nursing terminal, electronic health record platform and hospital management platform are realized in system data sharing and are synchronizeed by communication interface separately.The nurse can generate a nursing assessment view after PDA terminal typing nursing assessment,
This viewdata shares to the Hospital Electronic Medical Record system, and electronic medical record system can generate patient's care regimen and the executive logging figure of nursing assessment, as Figure 12.
PDA typing evaluation item is:
Mind > clear
Grow normal
Nutrition > medium
Face > normal
Be admitted to hospital (mode) walking
Comprise following content after nursing assessment view:
" sanity, grow normally, and nutrition is medium, normal face, the walking of being admitted to hospital.Totally 15 minutes "
Add and quote and do change during electronic health record platform typing NN, generate patient's care regimen and the executive logging figure of nursing assessment:
" sanity, grow normally, and nutrition is medium, normal face, and walking is admitted to hospital.Totally 15 minutes ".
In sum, the present invention is by portable PDA nursing terminal, obtain disease that calls for specialized treatment care regimen and the nursing appreciation information safeguarded, whenever and wherever possible must be in the optional position, lesion, according to PDA nursing terminal information, instruct the nurse, patient is carried out to standard, specialty, comprehensively nursing assessment and processing, reduce nursing cost, and the content after assessment is linked by PDA nursing terminal and electronic health record platform and hospital management platform computer terminal, realize data sharing, care regimen is carried out and nursed appreciation information and be saved in the electronic structure case history.
Above are only the specific embodiment of the present invention, but design concept of the present invention is not limited to this, allly utilizes this design to carry out the change of unsubstantiality to the present invention, all should belong to the behavior of invading protection domain of the present invention.
Claims (6)
1. the electronic medical record system based on wireless handheld terminal, is characterized in that: comprise
The PDA nursing terminal, comprise training sickness nursing module for creating and carry out care regimen and for assessment of the nursing evaluation module of the implementation status of this care regimen;
The hospital management platform, comprising can be for the specific nursing knowledge base of training disease information, care regimen and the nursing appreciation information of inquiring about for storage;
The electronic health record platform, for the care regimen that generates patient and the executive logging figure that nurses assessment;
Connect and realize data sharing by network between this PDA nursing terminal, hospital management platform and electronic health record platform; This PDA nursing terminal accesses the specific nursing knowledge base of hospital management platform by wireless network, retrieve and show set care regimen and nurse appreciation information, carry out the operation of training sickness nursing and nursing evaluation operation as foundation, and the executive logging of care regimen and nursing evaluation operation is shared to the electronic health record platform, the electronic health record platform generates patient's care regimen and the executive logging figure of nursing assessment.
2. a kind of electronic medical record system based on wireless handheld terminal as claimed in claim 1 is characterized in that: described training sickness nursing module comprise show and can be for the newly-increased care regimen unit of operation, carry out the nursing content unit, complete the care regimen unit and interrupt the care regimen unit.
3. a kind of electronic medical record system based on wireless handheld terminal as claimed in claim 1 is characterized in that: described nursing evaluation module comprise show and can nurse assessment unit, project evaluation unit, assessment every day for the interpolation of operation after automatically quantize the mark unit and generate the assessment view unit.
4. a kind of electronic medical record system based on wireless handheld terminal as claimed in claim 1, it is characterized in that: the training disease information of described specific nursing knowledge base comprises training disease name, stage schedule, effective marker, operation sign.
5. a kind of electronic medical record system based on wireless handheld terminal as claimed in claim 1, it is characterized in that: the care regimen of described specific nursing knowledge base comprises stage schedule, nursing items and the contents of a project, a training sickness nursing scheme can be divided into a plurality of nursing stage schedules, under each nursing stage schedule, divides again a plurality of nursing items and the contents of a project.
6. a kind of electronic medical record system based on wireless handheld terminal as claimed in claim 1, it is characterized in that: the nursing assessment of described specific nursing knowledge base comprises that the nursing evaluation item is safeguarded, nursing assessment inventory is safeguarded and nursing assessment distribution, a disease that calls for specialized treatment nursing assessment can have a plurality of evaluation items, and each evaluation item has a plurality of sub-projects.
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Cited By (11)
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| CN104123691A (en) * | 2014-08-15 | 2014-10-29 | 南京市卫生信息中心 | Regional electronic medical record management system based on layout electronic file technology |
| CN104504636A (en) * | 2014-12-31 | 2015-04-08 | 宁波江东索雷斯电子科技有限公司 | New clinic electronic records management system |
| CN105678671A (en) * | 2015-12-29 | 2016-06-15 | 北京嘉和美康信息技术有限公司 | Method and apparatus for generation of electronic medical record, mobile terminal and electronic medical record system |
| CN106599535A (en) * | 2016-11-16 | 2017-04-26 | 荣科科技股份有限公司 | Structurized shift arrangement system for hospital |
| CN106650210A (en) * | 2016-10-02 | 2017-05-10 | 张家港市锦丰镇人民医院 | Comprehensive nursing risk assessment system |
| CN108182971A (en) * | 2018-01-26 | 2018-06-19 | 康美健康云服务有限公司 | Nursing method, device and computer readable storage medium |
| CN108231204A (en) * | 2018-01-26 | 2018-06-29 | 康美健康云服务有限公司 | Look after generation method, device and the computer readable storage medium of plan |
| CN110742578A (en) * | 2018-07-24 | 2020-02-04 | 湖南花猫博士医疗科技有限公司 | Pressure sore assessment method, device and system |
| CN111418024A (en) * | 2017-09-27 | 2020-07-14 | 芝加哥康复研究院 | Rehabilitation status evaluation and management system and related method |
| CN112687367A (en) * | 2020-12-29 | 2021-04-20 | 中国人民解放军总医院 | Medical record grouping method, device and equipment based on dynamic disease condition and storage medium |
| CN113125764A (en) * | 2019-12-30 | 2021-07-16 | 深圳迈瑞生物医疗电子股份有限公司 | Sample analyzer, automatic maintenance method thereof and readable storage medium |
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Cited By (13)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN104123691A (en) * | 2014-08-15 | 2014-10-29 | 南京市卫生信息中心 | Regional electronic medical record management system based on layout electronic file technology |
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| CN105678671A (en) * | 2015-12-29 | 2016-06-15 | 北京嘉和美康信息技术有限公司 | Method and apparatus for generation of electronic medical record, mobile terminal and electronic medical record system |
| CN106650210A (en) * | 2016-10-02 | 2017-05-10 | 张家港市锦丰镇人民医院 | Comprehensive nursing risk assessment system |
| CN106599535B (en) * | 2016-11-16 | 2020-12-15 | 荣科科技股份有限公司 | Structured scheduling system of hospital |
| CN106599535A (en) * | 2016-11-16 | 2017-04-26 | 荣科科技股份有限公司 | Structurized shift arrangement system for hospital |
| CN111418024A (en) * | 2017-09-27 | 2020-07-14 | 芝加哥康复研究院 | Rehabilitation status evaluation and management system and related method |
| CN108182971A (en) * | 2018-01-26 | 2018-06-19 | 康美健康云服务有限公司 | Nursing method, device and computer readable storage medium |
| CN108231204A (en) * | 2018-01-26 | 2018-06-29 | 康美健康云服务有限公司 | Look after generation method, device and the computer readable storage medium of plan |
| CN110742578A (en) * | 2018-07-24 | 2020-02-04 | 湖南花猫博士医疗科技有限公司 | Pressure sore assessment method, device and system |
| CN113125764A (en) * | 2019-12-30 | 2021-07-16 | 深圳迈瑞生物医疗电子股份有限公司 | Sample analyzer, automatic maintenance method thereof and readable storage medium |
| CN113125764B (en) * | 2019-12-30 | 2023-08-25 | 深圳迈瑞生物医疗电子股份有限公司 | Sample analyzer, automatic maintenance method thereof and readable storage medium |
| CN112687367A (en) * | 2020-12-29 | 2021-04-20 | 中国人民解放军总医院 | Medical record grouping method, device and equipment based on dynamic disease condition and storage medium |
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Application publication date: 20131211 |