JP2000315241A - Electronic chart system - Google Patents

Abstract

PROBLEM TO BE SOLVED: To provide an electronic chart system to be made into a data base and to be structured as an electronic chart while permitting free writing by a doctor. SOLUTION: This electronic chart system is composed of an image area 2 in which a display body 1 of the electronic chart is used as a memorandum area of the doctor by expressing handwritten diagnostic contents, etc., by the doctor in a medical act in a form as it is, a text data area 3 in which data about the medical act related to the image area 2 is recorded by text by the doctor and which is used for a database system and an index area 4 in which a keyword described in a keyword fetching part 5 formed in the text data area 3 is fetched and recorded and which is used as an index to call a group of files corresponding to the keyword by selecting the keyword.

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 system for converting medical information relating to medical treatment into electronic information using a computer and managing the medical information in a file which can be stored and managed in a searchable state. Things.

[0002]

2. Description of the Related Art As a conventional electronic medical record,
Some use a template method. In this template method, a method is used in which a doctor substitutes a key term into a sentence having a predetermined syntax form as appropriate using a keyboard or a mouse.

[0003]

In the above-described conventional electronic medical chart of the template system, the key term is substituted into a pre-formed syntax, so that the entry is simple. Since the contents are limited to a prepared syntax, free writing by a doctor, which is usually performed on a paper chart, is not guaranteed at all.

For this reason, in recent years, there has been an electronic medical record called a dynamic template, which is an improvement over a conventional fixed template. The dynamic template detects the semantic content substituted in the syntax and dynamically changes the configuration of the template according to the content. However, since the patient's complaints, observation items, physicians' tactics, etc., change significantly during the actual series of medical treatments, there are no fixed guidelines for creating medical charts. Even so, it gave the clinician the cramped impression of applying his thoughts to certain forms. In other words, in the actual medical practice, for example, even in the case of outpatient examination for malignant tumors, the medical treatment often involves the patient's blood pressure or hemorrhoids that have been suffering for a long time. It is clear from this that the medical treatment content itself is not structured, and it is impossible to forcibly structure a medical chart using a template or the like.

[0005] Therefore, an object of the present invention is to solve the above problems and to realize an electronic medical record that allows a doctor to freely write data, and also makes a database and structure as an electronic medical record.

[0006]

In order to achieve the above object, an electronic medical record system according to the present invention provides a medical examination by hand by a physician, contents such as data on a patient taken from a scanner, and contents from other applications. An image area used as a doctor's memo writing area by recording the clip art related to the patient or the patient's medical examination contents etc. entered from the keyboard as it is, and the doctor records data related to the medical practice related to the image area as text A text data area used for a database system, and an index for fetching and recording a keyword written in a keyword fetching unit formed in the text data area, and for calling a file group corresponding to the keyword by selecting the keyword. It is to characterized in that it comprises an index area having the function of and.

Further, the image area, the text data area, and the index area are displayed on a screen of a display device of a computer.

[0008] The present invention is also characterized in that it is acceptable to input a keyword only to the keyword fetching unit and not to input it to the image area and the text data area.

[0009] The image area and the text data area are configured so that the contents to be written in one medical practice are formed on one page, and the index in the index area is configured so that the headings of each medical practice are consecutive in time series. It is characterized by the following.

[0010] The index area is characterized by displaying time-series data such as the date of consultation and a keyword integrally.

[0011]

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS FIG. 1 shows one screen displayed on a display device of a computer in an electronic medical record system according to the present invention. In the drawing, reference numeral 1 denotes a display of the electronic medical record. This electronic medical record is continuously recorded in a time-series manner as a file for each patient, similarly to the conventional paper medical record. 2 in the figure
Is the contents of medical examinations by doctors' handwritten medical examinations, data on patients captured from scanners, etc.
An image area 3 which represents the patient's medical information related to the image area 2 in the form of an image area representing the patient's medical examination contents or the like inputted from the keyboard or the clip art relating to the patient input from another application. A text data area for using in a database system,
An index area 4 is used as an index for automatically taking in the text at the beginning of the text data area 3 as a keyword and calling the image area 2 and the text data area 3.

The contents shown in the image area 2 are the writing of a medical chart used as a memo for the doctor, and the doctor freely writes down the information without specifying the format. By accumulating such memos, the doctor's measures for the patient are formed, and inquiries, visual inspection, palpation, auscultation, and the like are further performed according to the doctor's gradually evolving policy, and certain diagnostic actions are performed. Specifically, a doctor takes in an appropriate sheet on which a memo is written down by a scanner, and various pointing devices such as a tablet, a digitizer, a touch panel, a touch screen, a light pen, a mouse, a trackball, a stick, and a pad, which are computer input devices. Using a device or the like, the user writes notes such as pictures, figures, characters, and the like, pastes clip art related to the patient from other application software, and inputs medical examination contents and the like related to the patient from a keyboard using characters. The image area 2 is an area handled as an image. Although image data and the like are stored as mere image files, data input as text does not function as a database, but a format searchable by a full-text search method is used. Reserved. Then, the content represented in the image area 2 is recorded as a file (not shown) in a format that allows such work in a storage device of the computer.

In the text data area 3, a series of medical treatments such as inquiry, visual inspection, palpation, auscultation, etc. are performed in the process of writing a memo by the doctor in the image area 2.
As a result of these procedures, orders for clinical tests, medications, operations, and the like are determined. At this stage, since the doctor's thinking has already been organized, the medical treatment content can be described in a structured text to some extent, and therefore, it is possible to create a database that describes this medical treatment content. Become. Similarly, since it is easy for a doctor to create a certain keyword from these medical treatment contents, the text data area 3
Is provided with a keyword fetching unit 5 at the beginning, and about 50 characters (not particularly limited to the number of characters) written by the doctor are automatically copied as keywords 6 to the index area 4 located on the left side of FIG. And The contents represented in the text data area 3 are recorded as an appropriate data file (not shown) in the storage device of the computer.

In the index area 4, past asperities related to the medical treatment contents of one patient are accumulated in a time series as a set of the date of medical treatment and a keyword 6. By selecting and specifying with the keyboard, the text data area 3 and the image area 2 are called from the copy source file group linked by the keyword 6 and displayed on the screen. In the figure, reference numeral 7 denotes a scroll bar, which can be used to scroll up and down the index area 4 by using a mouse or a keyboard to display and search past asphalt. In other words, scrolling through the index area 4 is enough to view the past asphalt summaries, and when browsing the contents of the more detailed medical chart itself, double-clicking the keyword of that chart will display it on the right side. At this time, a pair of the image area 2 and the text data area 3 which are the medical charts are developed. The contents indicated in the index area 4 are reserved as appropriate indexes in the storage device of the computer.

As a series of operations relating to the electronic medical record of the present invention, each time a medical procedure is performed on a patient, a physician calls up a file of the electronic medical record of the patient with a computer, selects a medical record writing mode, and automatically or manually inputs the file. The date of the medical treatment, the medical care department, and the name of the doctor to be filled in are described in, for example, the upper row of the image area 2 and the lower row of the index area 4. In the medical examination, the doctor can write freely in the image area 2 using, for example, a touch screen or the like. Write memo 8 as a fragment of thought. In the figure, reference numeral 9 denotes patient test data copied and pasted by a doctor from a server for managing medical data in a hospital, for example. You can also decorate freely by coloring the letters.

[0016] As a result of the series of medical treatments, the physician can order a clinical test, administer medication,
While making an operation decision, etc., the contents are described as a summary in the text data area 3 using a keyboard, and the doctor can use the described contents as an index to refer to at the next and subsequent consultations. Keyword 6
Is selected and described in the keyword capturing unit 5. Then, this keyword 6 automatically becomes index area 4
Is linked and copied to the bottom of

The image area 2 and the text data area 3 may be left blank, so that in a busy outpatient department, the keyword fetching unit 5 indicates "no change".
It is enough to function as a medical chart just to describe. Unless such simplicity is provided, the electronic chart will take a lot of time to write down and the patient's consultation itself will be neglected. There is a risk of falling.

In the display of the image area 2 and the text data area 3 described above, both areas do not necessarily have to fit within one screen. For example, similarly to the index area 4, a scroll bar is provided and each area is wide. The display area may be secured. Although not specifically shown, not only the image area 2, the text data area 3, and the index area 4 are always displayed on the display device of the computer, but also the image area alone or the image area and the text data area are displayed. By doing so, a person using the electronic medical record of the present invention can appropriately select display.

Regarding the contents of the past electronic medical records, the system of hardware or / and software is designed so that tampering, such as erasing or rewriting, cannot be performed regardless of accident or intention in order to ensure the reliability of the medical records. It is necessary to set security thoroughly.

[0020]

According to the conventional electronic medical record, there is an attempt to convert the contents of the medical record into a database. Therefore, the emphasis has been placed on structuring the contents of the medical record to make it easier to convert the contents into a database. It was necessary to structure patient attributes, insurance information, and medical information, and it was relatively easy to achieve them. However, for a medical record, which is a record of medical treatment by a doctor in a narrow sense, it was not possible to require a strict structure, and it was difficult to implement the structure. Therefore, according to the present invention, the daily medical record is close to a memo written by a doctor, so that the medical record is not structured and is only stored in the original data. This is to structure the subset. This makes it possible for doctors to write freely, while creating a database as an electronic medical record,
An extremely easy-to-use electronic chart system that can be structured can be obtained.

Further, by displaying the image file, the text data file, and the index file on the screen of the display device of the computer, it is possible to freely write and structured text that is organized into a database based on thoughts organized based on this. , And the accumulated past medical history
The mutual association is clearly displayed.

Also, by accepting that a keyword is input only to the keyword taking-in section and not to the image area and the text data area, it is possible to sufficiently function as a medical record even by simply writing, for example, "no significant change" in the keyword writing section. This makes it possible to greatly reduce the time and effort required to enter a medical record when the user is busy.

Further, the image area and the text data area are configured so that the contents to be written in one medical practice are formed on one page, and the index of the index area is configured so that the headings of each medical practice are consecutive in time series. Thus, it is possible to roughly grasp the index by referring to the past medical history, and it is also possible to easily browse the more detailed medical record itself.

[Brief description of the drawings]

FIG. 1 is an explanatory diagram of a display of an electronic medical record according to the present invention.

[Explanation of symbols]

 1 Electronic medical record display 2 Image area 3 Text data area 4 Index area 5 Keyword import section 6 Keyword 7 Scroll bar 8 Memo 9 Test data

Claims (5)

[Claims] 1. The contents of a medical examination by hand of a doctor in medical practice, contents of data on a patient taken from a scanner, a clip art of a patient taken from another application, or contents of a medical examination of a patient inputted from a keyboard, etc. An image area that is recorded as a memo writing area of a physician, a text data area that is used by a physician to record data relating to medical actions related to the image area as a text and used in a database system, and a keyword formed in the text data area An electronic device comprising: an index area having a function as an index for capturing and recording a keyword written in a capturing section and selecting a keyword to call a group of files corresponding to the keyword. Medical chart system. 2. The electronic medical record system according to claim 1, wherein the image area, the text data area, and the index area are displayed on a screen of a display device of a computer. 3. The electronic medical record system according to claim 1, wherein a keyword is input only to the keyword input unit and not to the image area and the text data area. 4. The image area and the text data area are configured so that the contents to be written in one medical practice are formed on one page, and the index in the index area is configured so that the headings of each medical practice are consecutive in time series. The electronic medical record system according to claim 1, wherein: 5. The electronic medical record system according to claim 1, wherein time-series data such as the date of consultation and a keyword are integrally displayed in the index area.