(1) Structured data entry.
① Basic conditions for structured data entry
A large amount of information in the case can be directly structured data entry by healthcare professionals, and the basic conditions for structured data entry are structured system models, knowledge-driven content, predefined vocabularies, and rules for synthetic expressions.
②Structured data entry methods
(2) Natural language data entry. (NLP)
The advantage of NLP is that physicians do not have to change their accustomed way of recording when writing cases, and are free to express a variety of information. They can use handwritten text or tape recordings. For recordings, NLP systems can use speech recognition systems to analyze sentences in natural language and process the medical information contained in them for data entry.The most basic function of NLP is to generate indexes of the terms used, and these indexes can extract text containing one or more and specified terms, which NLP will be able to process in connection with each other to make inferences.
(3) Bio-signal and Medical Image Processing
With the introduction of a large number of digitized instruments and equipment in hospitals and the application of medical information systems such as LIS, PACS, etc., bio-signals and medical images have been gradually digitized through their processing and can be integrated into the electronic medical record by using the system's interfaces to integrate these digitized medical information.
The transfer of information between different systems is through the interface of the system, and information standardization is the key to the interface. When two systems use the same standard, transferring information is very simple. If the two systems are not using the same standard, the interface must convert the information, either by the system sending the information through the interface to convert the data into a format that the system receiving the information can understand, or by the receiving system through the interface to convert the data into a format that can be understood. The standardization of information is a gradual process, and in order to facilitate interfaces between systems using non-standard information, interface engines have been developed that use interface engines to convert non-standardized information into standardized information.
(4) Signature and change of electronic medical records
Medical records are documents with legal effect, and medical data has the role of legal evidence. The security of medical data in the medical record is extremely important, which not only maintains the interests of patients, but also maintains the interests of medical personnel. Every time you write an electronic medical record, you have to sign it before it takes effect. If you re-open the electronic medical record to change the operation, the EPR system will carry out different processing for different change of people, such as the previous level of physicians to delete or add content to the medical record, the system will automatically delete the content of the red and add a horizontal line in the middle of the text; if it is the director of the doctor to delete or add content to the medical record, the system will automatically delete the content of the red and add two horizontal lines in the middle of the text, and the new added content of the red and add two The system automatically turns the deleted content red and adds two horizontal lines in the middle of the text, and the newly added content turns red and adds two horizontal lines under the text.