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CN-121986379-A - Electronic medical record generation method, device, computer equipment and readable storage medium

CN121986379ACN 121986379 ACN121986379 ACN 121986379ACN-121986379-A

Abstract

The application relates to a method, a device, computer equipment and a readable storage medium for generating an electronic medical record. The method comprises the steps of obtaining diagnosis information of a diagnosis object (S102), determining generation scene information of an electronic medical record of the diagnosis object according to the diagnosis information (S104), determining medical record generation agents matched with the generation scene information (S106), and generating the electronic medical record of the diagnosis object based on the medical record generation agents (S108).

Inventors

  • CHEN ZEJIAN
  • Liao shu

Assignees

  • 上海联影智能科技股份有限公司

Dates

Publication Date
20260505
Application Date
20251229

Claims (15)

  1. 1. A method of electronic medical record generation, the method comprising: Acquiring diagnosis information of a diagnosis and treatment object; determining the generated scene information of the electronic medical record of the diagnosis and treatment object according to the diagnosis and treatment information; determining medical record generation agent matched with the generation scene information, and Generating the electronic medical record of the diagnosis and treatment object based on the medical record generating agent.
  2. 2. The method of claim 1, the obtaining the treatment information of the subject, comprising: receiving symptom information of the diagnosis and treatment object input by a user, and And obtaining the diagnosis information of the diagnosis and treatment object according to the symptom information and the pre-acquired object information of the diagnosis and treatment object.
  3. 3. The method of claim 2, the receiving symptom information of the subject entered by a user, comprising: the symptom information of the user voice input is received.
  4. 4. The method of claim 2, the receiving symptom information of the subject entered by a user, comprising: And receiving the symptom information manually input by the user.
  5. 5. The method of claim 1, wherein determining the generated scene information of the electronic medical record of the diagnosis and treat object according to the diagnosis and treat information comprises: And inputting the diagnosis information into a trained scene recognition model to obtain the generated scene information of the electronic medical record, wherein the generated scene information comprises at least one of an application scene and a scene requirement of the electronic medical record.
  6. 6. The method of claim 1, the determining medical record generation agent that matches the generation context information, comprising: Determining a cooperative unit and a scheduling instruction corresponding to the cooperative unit according to the generated scene information, wherein the cooperative unit comprises at least one of an intelligent model and a service module, and And obtaining the medical record generation agent according to the coordination unit and the scheduling instruction.
  7. 7. The method of claim 1, the generating an agent based on the medical record, the generating the electronic medical record of the medical treatment object, comprising: The prepositive information of the diagnosis and treatment object is obtained, wherein the prepositive information comprises at least one of an inspection result, a test result and a past medical record; determining expertise associated with symptom information of the subject; Obtaining a target diagnosis result of the diagnosis and treatment object according to the professional knowledge, the prepositive information and the diagnosis and treatment information of the diagnosis and treatment object, and And generating the electronic medical record of the diagnosis and treatment object according to the target diagnosis result.
  8. 8. The method of claim 7, wherein the medical record generation agent comprises an information extraction model; The obtaining the pre-information of the diagnosis and treatment object comprises the following steps: And extracting the prepositive information of the diagnosis and treatment object from a preset diagnosis and treatment information database by scheduling the information extraction model.
  9. 9. The method of claim 7, wherein the medical record generation agent comprises an information retrieval model; The determining expertise associated with symptom information of the subject includes: and searching the expertise corresponding to the symptom information from a preset expertise database by scheduling the information retrieval model.
  10. 10. The method of claim 1, the generating an agent based on the medical record, the generating the electronic medical record of the medical treatment object, comprising: acquiring personalized templates of the electronic medical records And generating the electronic medical record of the diagnosis and treatment object according to the personalized template.
  11. 11. The method of claim 10, prior to obtaining the personalized template for the electronic medical record, the method further comprising: Acquiring a history of a doctor; Extracting text features of the history, the text features including at least one of language features, structural features, and format features, and And determining the personalized template of the doctor according to the text characteristics.
  12. 12. The method of claim 1, after generating an agent based on the medical record, generating the electronic medical record of the medical treatment object, the method further comprising: Acquiring interaction information of doctors aiming at the electronic medical record; according to the interaction information, determining modification intention information of the doctor for the electronic medical record; Determining new medical record generating agent according to the modification intention information, and Generating an agent based on the new medical record, and generating a new electronic medical record of the diagnosis and treatment object.
  13. 13. An electronic medical record generation device, the device comprising: the information acquisition module is used for acquiring the diagnosis information of the diagnosis and treatment object; The scene determining module is used for determining the generated scene information of the electronic medical record of the diagnosis and treatment object according to the diagnosis and treatment information; a model determining module for determining medical record generating agent matched with the generating scene information, and And the medical record generation module is used for generating an agent based on the medical record and generating the electronic medical record of the diagnosis and treatment object.
  14. 14. A computer device comprising a memory and one or more processors, the memory having stored therein computer-readable instructions that, when executed by the one or more processors, cause the one or more processors to implement the steps of the method of any of claims 1 to 12.
  15. 15. One or more non-transitory computer-readable storage media storing computer-readable instructions which, when executed by one or more processors, cause the one or more processors to implement the steps of the method of any one of claims 1 to 12.

Description

Electronic medical record generation method, device, computer equipment and readable storage medium Technical Field The application relates to a method, a device, computer equipment and a readable storage medium for generating an electronic medical record. Background The electronic medical record writing system is used as a core basic module of a hospital information management system and bears core functions of digital recording of diagnosis and treatment behaviors, accurate supervision of medical quality, integration of hospital operation data and the like. Although the current system has realized the basic digital function, the current system is limited by a customized development mode, the performance of the current system is difficult to meet clinical requirements, and the current system is particularly characterized in that a model for generating an electronic medical record is usually trained for a specified application scene and is inconvenient to replace or expand, when the user requirement is changed, the structure of the model is required to be manually adjusted, the model after adjustment is retrained, the electronic medical record is generated by utilizing the model obtained through retrained, and the generation efficiency of the electronic medical record is low. Disclosure of Invention According to various embodiments of the present application, there is provided an electronic medical record generating method, apparatus, computer device, computer readable storage medium and computer program product. An electronic medical record generation method, comprising: Acquiring diagnosis information of a diagnosis and treatment object; determining the generated scene information of the electronic medical record of the diagnosis and treatment object according to the diagnosis and treatment information; determining medical record generation agent matched with the generation scene information, and Generating the electronic medical record of the diagnosis and treatment object based on the medical record generating agent. An electronic medical record generating device, comprising: the information acquisition module is used for acquiring the diagnosis information of the diagnosis and treatment object; The scene determining module is used for determining the generated scene information of the electronic medical record of the diagnosis and treatment object according to the diagnosis and treatment information; a model determining module for determining medical record generating agent matched with the generating scene information, and And the medical record generation module is used for generating an agent based on the medical record and generating the electronic medical record of the diagnosis and treatment object. A computer device comprising a memory and one or more processors, the memory having stored therein computer-readable instructions that, when executed by the one or more processors, cause the one or more processors to implement the steps of: Acquiring diagnosis information of a diagnosis and treatment object; determining the generated scene information of the electronic medical record of the diagnosis and treatment object according to the diagnosis and treatment information; determining medical record generation agent matched with the generation scene information, and Generating the electronic medical record of the diagnosis and treatment object based on the medical record generating agent. One or more non-transitory computer-readable storage media storing computer-readable instructions that, when executed by one or more processors, cause the one or more processors to implement the steps of: Acquiring diagnosis information of a diagnosis and treatment object; determining the generated scene information of the electronic medical record of the diagnosis and treatment object according to the diagnosis and treatment information; determining medical record generation agent matched with the generation scene information, and Generating the electronic medical record of the diagnosis and treatment object based on the medical record generating agent. A computer program product comprising program instructions which, when executed on a computer, cause the computer to carry out the steps of: Acquiring diagnosis information of a diagnosis and treatment object; determining the generated scene information of the electronic medical record of the diagnosis and treatment object according to the diagnosis and treatment information; determining medical record generation agent matched with the generation scene information, and Generating the electronic medical record of the diagnosis and treatment object based on the medical record generating agent. The details of one or more embodiments of the application are set forth in the accompanying drawings and the description below. Other features, objects, and advantages of the application will be apparent from the description and drawings, and from the claims. Drawings In order t