基于语音识别的智能电子病历（四）语音识别的要求 3

前一章讲的是不同医院对语言识别结果的个性化需求，现在说一下不同的医生对于识别结果的需求。我们看下面的这个例子，例子中对很多细节都有明确的要求。

004X医院4811XX医生 规范

 

1. 医生基本信息：4811XX--dictating doctXXXX H. LXXXXX MD-CARD 心脏科
2. 常用报告模板：0001--History and Physical; 0002--Consultation; 0003--Operative Report; 0004--Discharge Summary; 0005--Pre-Op H&P; 0006--Cardiology; 0016--Procedure Note.
3. 模板字体：RIS的信息： Arial Narrow 10号字; cc 开始及报告正文： Arial 10号字
4. 录音特点：有口音 ，语速较慢，以testing testing testing good day this is doctor JXXXX LXXX dictating discharge summary/consultation/preop history and physical for PATIENT last NAME spell xx first name xx and date admission xx date of discharge xx 开始。 以please fax a copy to my office and fax a copy to Dr. xx and Contact the patient for the dentist to give him a copy of this dictation thank you 之类句子结尾，不需要写进报告.
5. 报告细节：

·所有的大标题和次标题都只要大写，不要加粗，除了ALLERGIES；按照录音来确定有哪些标题.

·PE部分小标题分行写, 各个小标题之间空一行.

·分点时的提示语是new line，分段是 next paragraph，有时候会念混，要注意区分.

·医生常常念疾病名称的首字母缩写，编辑报告时需要全部展开.

·报告中病人的名字用 the patient 代替.

1. 主要大标题有：

0001--History and Physical

·BRIEF HISTORY:

·HISTORY OF PRESENT ILLNESS:

·ALLERGIES:

·PAST MEDICAL HISTORY: 

·CURRENT MEDICATIONS:

·FAMILY HISTORY: 

·SOCIAL HISTORY:

·REVIEW OF SYSTEMS:

·PHYSICAL EXAMINATION:

·LABORATORY DATA: 

·ASSESSMENT AND PLAN: 

 

0002--Consultation 所有的大标题都要大写加下划线

·DATE OF CONSULTATION:  （模板自带标题，不能删除）

·HISTORY OF PRESENT ILLNESS: (医生念BRIEF HISTORY，有时候两个都会念，这时要按照念的顺序编辑)

·ALLERGIES:  大写加粗 (内容一般为NO KNOWN DRUG ALLERGIES. 医生念的是 PAST MEDICAL HISTORY:)

·MEDICATIONS: 

·ADDITIONAL MEDICAL HISTORY: 

·SOCIAL HISTORY: 

·FAMILY HISTORY: 

·REVIEW OF SYSTEMS:   (成一段编辑，小标题大写)

·PHYSICAL EXAMINATION: 

·SIGNIFICANT LABORATORY:/SIGNIFICANT LABORATORY DATA: 

·ASSESSMENT AND PLAN: 

 

0003--Operative Report

·DATE OF SURGERY:  （模板自带标题，不能删除）

·PREOPERATIVE DIAGNOSES:  

·TITLE OF PROCEDURE: (医生念PROCEDURE)

·POSTOPERATIVE DIAGNOSES:   (医生念the same，把PREOPERATIVE DIAGNOSES部分粘贴过来就可以了)

·SURGEON: 

·ANESTHESIOLOGIST: 

·BRIEF HISTORY: 

·DESCRIPTION OF PROCEDURE:  (医生念COURSE PROCEDURE)

·DIAGNOSTIC DATA:  (医生不念此标题，参考内容为Postoperative chest x-ray showed no evidence of a pneumothorax or hemothorax.  )

·ESTIMATED BLOOD LOSS: 

·RADIATION TIME: 

·ASSESSMENT AND PLAN: 

 

0004--Discharge Summary

·DATE OF ADMISSION:  （模板自带标题，不能删除）

·DATE OF DISCHARGE:  （模板自带标题，不能删除）

·ADMISSION DIAGNOSES:

·DISCHARGE DIAGNOSES:  (医生念the same，把ADMISSION DIAGNOSES部分粘贴过来就可以了)

·PROCEDURE: 

·PHYSICIANS INVOLVED: 

·BRIEF HISTORY: 

·HOSPITAL COURSE:  (在BRIEF HISTORY下面，医生可能不念此标题，要根据内容自己判断)

·PHYSICAL EXAMINATION UPON DISCHARGED:  (小标题按照医生念的来编辑)

·SIGNIFICANT LABORATORY: 

·TROPONINS: 

·DISPOSITION: 

·DISCHARGE MEDICATIONS: 

·ACTIVITY LEVEL:  (常见内容Ad lib.)

·FOLLOWUP: 

 

0005--Pre-Op H&P

·BRIEF HISTORY:  (医生念常常念REASON FOR ADMISSION:  ，所以有时候也可以用这个标题)

·HISTORY OF PRESENT ILLNESS: 

·DRUG ALLERGIES OR REACTIONS:  (内容大写加粗，有时写作PAST MEDICAL HISTORY:  ，可以根据医生念的来编辑)

·CURRENT MEDICATIONS:

·OTHER MEDICAL HISTORY:

·SOCIAL HISTORY: 

·FAMILY HISTORY: 

·REVIEW OF SYSTEMS:  (医生会念new line分点，但是我们编辑成一段，小标题大写)

·PHYSICAL EXAMINATION:

·SIGNIFICANT LABORATORY:

·ASSESSMENT AND PLAN: 

 

0006--Cardiology

·DATE OF PROCEDURE:  （模板自带标题，不能删除）

·BRIEF HISTORY:

·INDICATIONS: 

·MEASUREMENTS:

·INTERPRETATION: 

·RECOMMENDATIONS:

·ASSESSMENT AND PLAN: 

 

0016--Procedure Note.

·DATE OF PROCEDURE:  （模板自带标题，不能删除）

·PREOPERATIVE DIAGNOSES: 

·PROCEDURE: 

·POSTOPERATIVE DIAGNOSES:  (医生念the same，把PREOPERATIVE DIAGNOSES部分粘贴过来就可以了)

·PHYSICIAN:

·BRIEF HISTORY:

·DESCRIPTION OF PROCEDURE: 

·ESTIMATED BLOOD LOSS: 

·COMPLICATIONS:

7.    REVIEW OF SYSTEMS:  的常见格式与内容：

REVIEW OF SYSTEMS:  No fevers, chills, night sweats or weight changes.  PSYCHOLOGICAL:  Mildly anxious, no acute decompensation or intentional tremor.  SKIN:  No bruises or moles.  HEARING:  No change.  VISION:  No change. PULMONARY:  No cough, hemoptysis, no history of tuberculosis.  CARDIOVASCULAR:  Please see history of present illness.  GASTROINTESTINAL:   No nausea and vomiting, diarrhea, constipation, flank pain, hematemesis, hematochezia.  GENITOURINARY:  No flank pain, dysuria, hematuria, urgency.  NEUROMUSCULAR:  No motor, sensory, cranial nerve deficiency.

      8.   PHYSICAL EXAMINATION常见格式与内容：

PHYSICAL EXAMINATION:

GENERAL:  Well-developed, well-nourished 67-year-old Mandarin-speaking male in mild abdominal pain.

 

VITAL SIGNS:  Blood pressure 111/65, pulse 70, respiratory rate 20.

 

SKIN:  No ecchymosis, scars noted.

 

HEENT:  The neck is supple, free range of motion.  Sclerae clear, no conjunctivitis.  External acoustic canal clear. 

 

CHEST:  Clear to auscultation.

 

CARDIOVASCULAR:  Regular rate and rhythm with 1/6 systolic murmur, positive S4.

 

ABDOMEN:  Positive bowel sounds, soft, nontender.

 

EXTREMITIES:  No cyanosis or clubbing with 1+ edema. 

 

LYMPHATICS:  Palpable supraclavicular lymph nodes.