Skills and methods. XMF editor adopts extensible logo architecture and double template technology, which solves the problems of structured organization and freedom of electronic medical records.
Input questions; Solve the common application problem of electronic medical records; Can be designed by non-computer personnel to meet different majors.
Clinical requirements of electronic medical record template. Using the binding rules of XMF editor can also solve the problem of blind copying of electronic medical records.
Questions with the same content.
Keywords: Electronic Medical Record Structured Liberalization Input Extensible Logo Architecture
1. Introduction
The input method of electronic medical record is the most important problem in the design and use of electronic medical record. How to design a structured
An electronic medical record writer or editor that can freely input data is a problem that the industry is concerned about and discussing.
In the development of electronic medical record software, we designed and used an extensible logo framework.
(Extensible Markup Framework) Electronic Medical Record Editor (hereinafter referred to as XMF Editor) solves the problem of electricity.
Structured organization and free entry of sub-medical records.
Different medical disciplines or specialties and different diseases have different descriptions and forms of medical record information.
Same; Even if it is the same disease, different hospitals, different doctors, different patients, descriptions and forms of medical record information.
It will be different now.
Therefore, it is difficult to solve medical activities by establishing input methods or editors of electronic medical record templates for different diseases.
In Chinese, different medical disciplines or specialties, different diseases and even the calendar information of the same disease have different descriptions and expressions.
Beg.
Moreover, in order to be structured, the medical records that should be freely input in natural language are organized into fixed words or phrases.
Electronic medical records of gender input will also affect doctors' thinking and destroy Chinese words into sentences, words into words and words diversification.
The natural language structure destroys the doctor's professional habits. For example, the chief complaint of acute appendicitis is described as "persistent right" in natural language
Abdominal pain for 4 hours. "If the main complaint input process of the electronic medical record is changed to: select the pain part" right lower abdomen, right upper abdomen,
Suburb? 6? 8"; Choose the type of pain "pain, tingling, sharp pain? 6? 8"; Choose the nature of pain "persistent, metastatic, 6? 8";
Select the number of times of pain 1, 2, 3, 4? 6? 8"; Select the pain time unit "minutes, hours, days?" 6? 8 "and so on.
Choosing and describing it as "right lower abdomen, pain, lasting for 4 hours" will have a great influence on the doctor's thinking mode of disease diagnosis and treatment.
The influence and limitations are great. Regardless of whether the influence of this method is good or bad. Any electronic medical record software, how many?
Ten thousand kinds of diseases, make a template for doctors to use, and choose more parts, symptoms and signs to meet clinical needs.
It is almost impossible to choose.
XMF editor is a technology used to identify, describe, organize, store and retrieve the input and output of electronic medical record information.
And method. MXF has an extensible markup function similar to XML. It is especially suitable for computers widely used in the medical field.
Non-computer professionals-used by medical personnel to meet the description and identification of complex medical information, according to any
2007 China Hospital Information Network Conference
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Seek the requirements of performance, acquisition and output. Meet the requirements of structured organization and free input of medical record information. Adapt to different situations
Universal design and application of electronic medical records in disciplines and specialties. The problem of electronic medical record information is solved through its extensible recognition function.
General input, output, selection, inclusion, editing, structured storage and its association with database, positioning and other issues.
2. The main functions of 2.XMF editor
2. 1 XMF editor is a double template electronic medical record editor.
Through the analysis of medical record information, we abstract medical record information into medical record organizational structure information and medical record content information.
The organizational structure of medical records depends on the provisions of relevant national laws and regulations, as well as the requirements of medical professionals. Although different doctors
Medical disciplines or specialties are different, but the organizational structure of medical records is always limited and universal in a certain range.
The content information of medical records is different not only in different medical disciplines or specialties, but also in different diseases, different patients and different doctors.
The contents of written medical records are different. The contents of medical records are not universal, so they should be freely input in natural language. this is
The characteristics of Chinese in China are also an inevitable requirement for future voice input.
Therefore, XMF editor divides electronic medical record templates into medical record structure templates and medical record content templates (case templates). Two sets
Templates cooperate to complete the organizational structure and input liberalization of medical record information.
The medical record structure template abstracts the organizational structure of medical record information and solves the problems of input, output, selection, inclusion,
Editing, structured storage, its association with database, positioning, information full-text retrieval and other issues. Can be designed to meet different students.
Medical record structure templates of departments and specialties, such as cardiology, orthopedics, ophthalmology, gynecology, traditional Chinese medicine and other medical record structure templates; is very good also
Design nursing document structure templates such as nursing records, special nursing records and labor records; You can also design various inspections, tests,
Medical record structure template such as treatment application form and report form structure template. These templates are stored, called and retrieved in a unified way.
It's universal. In the medical record structure template, the granularity of medical record information structure can be arbitrarily selected and adjusted according to the needs of management.
On the basis of the medical record structure template, doctors in every hospital, department and specialty can freely introduce diseases.
Calendar content, you can also selectively input medical record content, and input multimedia medical record content such as text, graphics, sound and video.
Form a structured and personalized medical record example; You can also create a case template for each disease and copy it as the medical record of the same disease.
The template entered. Achieve the purpose of structuring the content of electronic medical records and liberalizing the input.
2.2 XMF editor is an electronic medical record editor used by medical staff.
Designers who use XMF editor's medical record structure template may be completely ignorant of any software programming technology.
Medical personnel themselves, such as doctors or nurses. Through the XMF editor, they can visually design what they see and see in the electronic medical record information.
Interface, input and output style, the relationship between design and database can be edited or modified, and letters are completed by XMF.
Display of information interface, data collection and structured storage of data. Better meet the clinical needs. Enhanced electronic medical record
Medical professionalism, enhance the clinical practicability of electronic medical records, realize what you see is what you get, and realize the structure of electronic medical records.
Storage, realize the full-text retrieval of electronic medical records.
XMF can map clinical models to logos through medical experts. In the process of mapping, through logo or extended logo,
Make the input and output interface of electronic medical record information completely consistent with the clinical model. At the same time, users can capture information in the medical field.
Professional experience is used to further analyze and modify XMF logo, forming a virtuous circle of XMF logo and element expansion.
Continuously improve the structural template to meet the needs of the development of clinical medicine.
2.3 XMF editor can solve the similarity problem of domestic electronic medical records.
In China, because the electronic medical records are input by copying the case template, it is common that the medical records are the same.
"Zhang Guan and Dai Li", "before and after, up and down, left and right, regardless of gender", "sameness" and other issues.
XMF editor dynamically changes the contents of medical records, such as the patient's name, gender, age and so on, through dynamic links with the database.
Information, such as: through the constraint rules of structural elements, limits the content that can be copied, such as personal medical history, and each patient is different.
No plagiarism, etc. Solve the problem that the electronic medical record is not modified in place after copying. Improve the input efficiency of electronic medical records. Address:/thread-18874-1-1.html