基于元数据的病案首页自动生成系统的研究

摘要

Nowadays front page plays an import role in medical records as it influences the quality deeply.However,front pages of medical records input mostly depend on plenty of manual work currently,which takes both time and energy of the medical worker to do such paperwork.Besides,low quality of medical records brought refused payment of medical insurance,and hospitals had to endure the unnecessary loss of money.Furthermore,since different hospitals use variety HIS database,uniform standards used to automatically generate front pages of medical records need to be defined.According to the problems above,we propose an automatic generation system of front pages of medical records based on metadata,which have run on heterogeneous database.The system also verified the validity of data automatically generated.After practical application,the system reduced manual work,improved data validity,and raised payment of medical insurance.%病案首页作为住院病案必不可少的组成部分,对病案质量有重要影响.目前主流的病案首页录入方式,存在手工录入较多、自动化生成程度低等问题,造成医务人员工作效率低,且人工填报容易空项或出错,从而导致医疗保险拒付,造成医院不必要的经济损失.此外,各大医院使用的HIS数据库各不相同,需要统一标准,实现病案首页的自动生成.针对上述问题,提出一种基于元数据的病案首页自动生成系统,适用于异构数据库,提高病案首页的自动化生成程度,并校验数据的合法性,经过实际应用,该系统简化了人工操作,提高了病案首页准确率,降低了医保拒付率,减少了医院的经济损失,达到了较好的效果.