JP2000194788A - Electronic patient's record device - Google Patents

Abstract

PROBLEM TO BE SOLVED: To manage the relation between the unchanged information and the changed information and also to display the unchanged information as necessary by holding the medical information display information having its unchanged contents and performing the display based on the display information. SOLUTION: A medical information management file 31 manages the display information on the medical information on every patient who is managed by an electronic patient's record device and produces a file per patient. A display information file 32 is shown in a display information file name included in the file 31. Thereby the file 32 also produces a file per patient. A changed information file 33 manages the changing state information contained in the changed medical information display information. The changing state information is managed for every medical information display information and shows one of uncorrected, addition, deletion, correction/deletion and correction/addition states. Thus, the relation is managed between the unchanged information and the changed information.

Description

DETAILED DESCRIPTION OF THE INVENTION

[0001]

BACKGROUND OF THE INVENTION 1. Field of the Invention The present invention relates to an electronic medical record apparatus for electronically storing information (medical care information) of items described in a medical record and displaying the information as needed.

[0002]

2. Description of the Related Art There has been provided a so-called electronic medical record apparatus in which medical treatment information is digitized and recorded, and is displayed on a screen as necessary. In the electronic medical record device, the items of the medical information displayed on the screen are the same as the items of the medical information described in the paper chart, and are used in the same manner. For example, a doctor displays a past prescription for a patient under medical treatment on a screen and uses it as a reference for the current prescription. Alternatively, a result of a blood test or the like performed in the past is displayed on a screen, and is used for grasping a patient's condition and verifying a therapeutic effect.

[0003]

SUMMARY OF THE INVENTION In an electronic medical record device,
After the doctor examines the patient and describes and approves the medical treatment in the medical record, the information stored electronically must be stored and restored in the same meaning and format as when it was created. Need to guarantee. for that purpose,
It is desirable to prohibit any change in the recorded contents after storage, but as long as the recorder is a human, there may be a mistake in the description, so a means for correcting the record is required.

In order to correct errors and prevent falsification of medical records, it is necessary to manage the relationship between the information before and after the change. In other words, in the case of a paper chart, traces of change / addition / deletion tend to remain, but in the case of an electronic chart recorded on a normal electronic recording medium, it is difficult to discriminate. Need to be related. In addition, in view of the fact that electronic medical records have a limited display area and the amount of information that can be displayed at one time is limited, the display of information before the change can be performed only when necessary. It is desirable to do.

An object of the present invention is to make it possible to manage the relationship between the information before change and the information after change in an electronic medical record, and to display the information before change as necessary. With the goal.

[0006]

According to the present invention, there is provided an electronic medical record apparatus for electronically storing information of each entry of a medical record and displaying the information on a screen, wherein the display information and the contents of each entry are changed. The change information indicating the type of medical information is stored as medical information display information in a one-to-one correspondence, and display is performed based on the medical information display information, with display information storage means for holding the medical information display information before the content change. And a display control unit. Claim 2
The invention of the present invention is an electronic medical record device that electronically stores information of each described item of a medical record and displays the information on a screen, wherein a medical treatment information input unit for inputting the content of each described item, a display information storage unit, Creating medical information display information for associating display information for displaying the input content in association with the described items and change information indicating the type of content change on a one-to-one basis;
Storage control means for storing in the display information storage means, display mode input means for specifying normal display or mixed display,
When normal display is specified, display based on only the medical information display information whose change information type is not deleted is performed, and when mixed display is specified, display based on medical information display information is performed regardless of the type of change information. And a display control means for performing the operation. According to a third aspect of the present invention, in the second aspect, the display control means performs the display based on only the medical information display information in which the type of the change information is not deleted when the normal display is specified, and specifies the mixed display. If the type of change information is deleted, a display indicating that the type of change information is deleted is displayed on the display character string, and the type of change information is highlighted. The electronic medical record device is characterized in that normal display is performed on the medical information display information in which the type of change information is uncorrected.

[0007]

FIG. 1 shows the configuration of an electronic medical record apparatus according to an embodiment. As shown, the electronic medical record device has a control device 20, a keyboard 11, a mouse (or other known pointing device) 12, a display 13, and a storage device 30. The control device 20 includes a program ROM, a working RAM, an MPU, a video RAM, and the like. Functionally, a system control unit 21 having a control function of the whole apparatus, a display control unit 22 having a display control function of the display 13, and a file recording / reproduction control unit 2 having a function of reading / writing each file in the storage device.
3 The storage device 30 is configured as a device having a recording medium such as a hard disk, for example. The storage device 30 includes a medical information management file 31, a display information file 32, and a change information file 33. It should be noted that other files other than these are also provided, but are not shown because they are not directly related to the present invention.

[0008] In the present specification, the medical care information refers to information of items described in a conventional paper chart, such as a medical history, a cause, a main symptom, and a progress. FIG. 2 is an example of a screen display in which patient medical information input, approved and recorded by a doctor as an operator is restored and displayed at a later date, that is, an example of an unmodified display screen. FIG. 3 shows an example of a screen on which the corrected and saved patient medical information is displayed after correcting the body temperature of the finding information, adding weight, deleting blood pressure and diarrhea in the medical information of FIG. It is an example of a later display screen. This display is displayed in the normal display mode. In the normal display mode, only the last information is displayed, and the deleted information is not displayed. However,
The information indicating the correction is displayed so as not to narrow the display area. For example, in order to indicate that the medical information has been changed, the first display header information line in the display area of FIG. 3 is displayed in a color (eg, green) other than black (standard color).

FIG. 4 shows an example of a display screen in the mixed display mode for displaying all the medical information before and after the change. In this screen, the deleted information is indicated by a horizontal line over the text,
The added information is displayed in a color (eg, green) other than black (standard color). In addition, with regard to the corrected information, the information before the correction is treated as a deletion and the information after the correction is treated as an addition, and the two are displayed side by side to clearly indicate that it is a correction.

The medical information management file 31 is a file for managing display information of medical information for each patient managed by the electronic medical record apparatus, and one file is created for each patient. The format is shown in FIG. FIG.
The display information file header position is information indicating the head position in the display information file of the patient in one medical care information unit (eg, the date of consultation), which is the display information identification corresponding to the position. No. (see FIG. 6A).
The number of display information is the number of display information in one medical information unit. In addition, the correction state is one medical information unit for one time,
This is information indicating whether the state is unmodified / added / deleted / modified.

The display information file (“display information storage means” in the claims) 32 is indicated by the display information file name in the medical information management file 31. Therefore, one display information file 32 is also created for each patient. FIG. 6A shows the format. In the figure, the display information identification number is a number for identifying medical care information display information. The medical care information display information is, for example, a minimum unit on display such as a body temperature and a classification display. In other words, it refers to an information unit corresponding to “1 described item” of the medical record. The change state information (“change information” in the claims) is a change state managed for each piece of medical information display information, and indicates whether the state is uncorrected / added / deleted / corrected / deleted / corrected / added. Information.
As described above, in the electronic medical record apparatus, even in the case of display information that has been deleted during the editing of the medical information, only the deletion state is internally set, and the information is not deleted. At the time of correction, a correction deletion state is set in the display information before correction, and a correction addition state is set in the display information after correction.

The change information file 33 is a file for managing the change state information in the changed medical information display information. FIG. 7 shows the format. The change information file 33 is used when displaying change date and time and changer information.

A procedure for displaying the screens shown in FIGS. 3 and 4 will be described. First, the display control employed by the electronic medical record apparatus will be briefly described. In the present electronic medical record apparatus, a display buffer is generated on a memory, medical information display data for a predetermined number of times M is written in the display buffer, and display is performed by allocating one screen size of display control from the display buffer. In the display buffer, the character display color attribute can be set for each character or character block when writing characters. Three display buffers are prepared, and when display information other than the specified display buffer is requested, switch to the corresponding display buffer or
Alternatively, when there is no corresponding display buffer, a necessary display buffer is prepared and switching is performed, and display control is performed by rewriting the unnecessary display buffer with necessary display information.
Two sets of three display buffers are prepared for normal display and mixed display of correction information, and are used by switching.

Next, a display preparation procedure for performing display will be described.
This will be described with reference to the flowchart of FIG. The user (doctor) selects a patient from the patient list, and specifies the medical information management file based on the patient identification number of the selected patient. The display information file is specified by reading the number of registered medical information management files and the display information file name. As the initial display, medical information on the latest consultation day is displayed. On the memory, the data is expanded from the top to the bottom of the display area in order from the oldest one, and the lowest part (latest part) is displayed on the screen. The latest information, that is, the medical information management information from the Nth registration number to the past M times necessary for the display buffer, that is, NM + 1 to N, is sequentially read. The display information file header position P, the number of display information Q, and the correction state R of the medical information for one time are read, and the display information from the display information identification number P to P + Q in the display information file 32 is sequentially read. The read display information is stored in a display information structure (see FIG. 7) composed of a display information identification number, display character information, and change state information. Stored in places up to Q.
In addition, a correction state R is stored in the 0th of each array. Thus, the display information arrays A1 to AQ are prepared.

Next, a procedure for displaying a display information array of one medical information will be described. FIG. 9 shows a display processing flow common to the screen displays of FIGS. 3 and 4. The array A1 will be described as an example. The 0th correction state R and the 1st display character information of the array A1 are read. If R is in the correction state, the color attribute of the first display information is set to a color other than black, for example, green, and is written to the display buffer. Alternatively, it is set to black and written to the display buffer. The first display character information is the information on the first line of the display screen example in FIG. 3 and is the header information of the medical treatment information. Modification of the header information after recording is prohibited. Then, 2
The A to Q are sequentially read, and the display information arrays A2 to AQ are sequentially written to the display buffer in the same manner as A1.

The display buffer writing process of FIG. 9 is processed as shown in FIG. 10 in the normal display mode. That is, the change state information R is checked, and if the state is the non-deletion (non-correction / addition / correction addition) state, the display color attribute is set to black, and the display color attribute is sequentially written to the display buffer. Those in the deleted state / changed deleted state are not written. At the time of writing to the display buffer, whether or not a line break is possible is determined based on the number of characters of display character information, the number of blank characters in a display category, and the number of displayable characters per line. I do. Thus, A1 to AQ
A display buffer is prepared based on the display information up to. When display control is performed based on the prepared display buffer, FIG.
Is displayed as follows.

To perform the display shown in FIG. 4, the display mode is switched to the mixed display. In the mixed display mode, a display buffer is prepared according to the following procedure. The display buffer for the normal display mode is left for later switching.
In the mixed display mode, the display buffer writing process in FIG. 9 is performed according to the procedure in FIG. That is, the change state information R is checked, and if the state is uncorrected, the color attribute is designated as black, and
In the correction addition state, a color other than black (eg, green) is designated and sequentially written to the display buffer. In the deletion state / change deletion state, a display attribute for adding a horizontal line indicating deletion is set and written to the display buffer. Instead of adding a horizontal line, color information such as blue, which can be identified (can be identified as non-corrected or added / modified added), may be set. In this way, the display information from A1 to AQ is sequentially written into the display buffer, and the display is performed based on the display buffer, thereby obtaining the screen display of FIG.

[0018]

According to the first aspect of the present invention, the display information of each item and the change information indicating the type of the content change are stored as the medical information display information in a one-to-one correspondence, and the medical information before the content change is stored. Since the information display information is held, the relationship between the information before the change and the information after the change can be managed. According to the invention of claim 2, when the normal display is designated, the display based on only the medical information display information whose change information type is not deleted is performed, and when the mixed display is designated, regardless of the type of the change information. Since the display based on the medical care information display information is performed, the information before the change can be displayed as needed. According to the third aspect of the present invention, the information before and after the change can be distinguished and displayed.

[Brief description of the drawings]

FIG. 1 is a block diagram showing a configuration of an electronic medical record device according to an embodiment.

FIG. 2 is an explanatory view exemplifying a medical information screen of a normal display without correction, addition or deletion.

FIG. 3 is an explanatory view exemplifying a medical information screen of a normal display after correction / addition / deletion;

FIG. 4 is an explanatory view exemplifying a medical information screen on which mixed information is displayed after correction, addition, and deletion.

FIG. 5 is an explanatory diagram showing a format of a medical care information management file.

6A is an explanatory diagram showing a format of a display information file, and FIG. 6B is an explanatory diagram showing a format of a change information file.

FIG. 7 is an explanatory diagram showing a display information array structure.

FIG. 8 is a flowchart illustrating a preparation procedure for displaying medical care information.

FIG. 9 is a flowchart showing a procedure for displaying medical care information.

FIG. 10 is a flowchart illustrating a buffer writing procedure in a normal display.

FIG. 11 is a flowchart showing a buffer writing procedure in the correction information mixed display.

[Explanation of symbols]

 32 Display information file 33 Change information file

Claims (3)

[Claims] 1. An electronic medical record apparatus for electronically storing information of each entry in a medical record and displaying the information on a screen, wherein the display information of each entry and change information indicating the type of content change are one-to-one. A display information storage unit that stores the medical information display information before the contents are changed and stored as the medical information display information, and a display control unit that performs display based on the medical information display information. Electronic medical record device. 2. An electronic medical record device for electronically storing information of each described item of a medical record and displaying the information on a screen, wherein a medical information input unit for inputting the contents of each described item, and a display information storage unit And display information for displaying the input content in association with the description item and change information indicating the type of content change in a one-to-one correspondence with the medical information display information, and store the display information in the display information storage means. Storage control means for storing, display mode input means for specifying normal display or mixed display, and when normal display is specified, the type of change information is displayed based on only non-deleted medical information display information, An electronic medical record apparatus comprising: display control means for performing display based on medical information display information regardless of the type of change information when mixed display is designated. 3. The display control unit according to claim 2, wherein the display control means performs display based on only the medical information display information in which the type of the change information is not deleted when the normal display is specified, and the mixed display is specified. In the case, the display of the medical information display information of which the type of the change information is deleted indicates that a pattern indicating the deletion is added on the display character string, and the display of the medical information of which the type of the change information is added is highlighted. An electronic medical record apparatus characterized in that normal display is performed for medical information display information in which the type of change information is uncorrected.