(1) structured data entry.

① Basic conditions of structured data input

A large amount of information in cases can be directly input by medical staff, and the basic conditions of structured data input are structured system model, knowledge-driven content, predefined vocabulary and synthetic expression rules.

② structured data entry method

(2) natural language data entry. (NLP)

The advantage of NLP is that doctors can freely express all kinds of information without changing their customary recording methods when writing cases. They can record with handwritten text or tape. For recording, NLP system can use speech recognition system to analyze sentences in natural language and process medical information contained in them, so as to input data. The most basic function of NLP is to generate indexes for the terms used. These indexes can extract texts containing one or more specified terms, and NLP will be able to relate them and make inferences.

(3) Biological signals and medical image processing

With the introduction of a large number of digital instruments and equipment in hospitals and the application of medical information systems such as LIS and PACS, biological signals and medical images have been gradually digitized through their processing, and these digitized medical information can be integrated into electronic medical records through the interface of the system.

information transmission between different systems is through the interface of the system, and information standardization is the key of the interface. When two systems use the same standard, it is very simple to transmit information. If the two systems are not using the same standard, the interface must convert the information, and the system sending the information will convert the data into a format that can be understood by the system receiving the information through the interface, or the receiving system will convert the data into an understandable format through the interface. The standardization of information is a gradual process. In order to facilitate the interface between systems using nonstandard information, people have developed an interface engine, which converts nonstandard information into standardized information.

(4) Signature and modification of electronic medical record

Medical record is a document with legal effect, and medical record data has the function of legal evidence. The security of medical data in medical records is extremely important, which not only protects the interests of patients, but also protects the interests of medical personnel. Every time you write an electronic medical record, you have to sign it before it can take effect. If you reopen the electronic medical record to make changes, the EPR system will deal with different changes for different people. When a doctor at the next higher level deletes or adds content to the medical record, the system will automatically turn the deleted content red and add a horizontal line in the middle of the text. If the chief physician deletes or adds content to the medical record, the system will automatically turn the deleted content red and add two horizontal lines in the middle of the text, and turn the newly added content red and add two horizontal lines below the text.