JP2000325314A - Electronic clinical card recording device and method thereof - Google Patents

Abstract

PROBLEM TO BE SOLVED: To easily and quickly record an electronic clinical card by anyone. SOLUTION: In the preparation of an electronic clinical card in a hospital computer, a pen-type input device, for instance, a liquid crystal pen tablet is adopted. Patterns for sketch of various lesion are previously registered in the hospital computer. When the drawing of the lesion is sketched, a doctor twice pen-touches drawing area 27a, 27b already entered on lesion drawing sheet 27 or without lesion drawing area 27c to carry out the sketch with a liquid crystal pen making a rough sketch of the pattern for sketch. When a DO input is carried out, the doctor twice pen-touches the desired indication part of the medical examination sheet 25, or pen-touches a DO input button 13 to display a DO input sheet, and pen-touches the medical examination check box of medical examination exhibited on the DO input sheet to carry out the DO input.

Description

DETAILED DESCRIPTION OF THE INVENTION

[0001]

BACKGROUND OF THE INVENTION 1. Field of the Invention The present invention relates to a technique for recording electronic medical records.

[0002]

2. Description of the Related Art Many hospitals have introduced an electronic medical record system for managing medical record information of each patient using an electronic medical record. Generally, each doctor at each hospital records an electronic medical record using a keyboard or a mouse of a personal computer terminal. In the creation of an electronic medical record, there are many cases in which the affected part of a patient is sketched, and the same action as the previous medical care action (prescription, treatment, injection, examination, etc.) is input (hereinafter referred to as DO input).

[0003]

The above sketch is performed by operating a mouse. Therefore, when you need to make detailed sketches, precise mouse operation is required,
Sometimes you spend time on sketching. On the other hand, D
The O input requires at least an operation for retrieving and displaying the previous medical practice, that is, a plurality of operations in order to perform the O input. The DO input is performed by searching for a desired previous medical treatment by scrolling the display screen or the like, and dragging and dropping (or copying and pasting) with the mouse.

[0004] Each of the above operations is cumbersome for a doctor, and especially for a doctor who is not good at computer operations.
Creating electronic medical records has become very cumbersome. As a result, consulting each patient may spend time creating an electronic medical record,
The consultation time may be longer than necessary.

Accordingly, an object of the present invention is to enable anyone to easily and quickly record an electronic medical record.

[0006]

According to a first aspect of the present invention, there is provided an electronic medical record recording apparatus including a pen-type input device and a model of an affected part relating to various parts of a human body. Is characterized in that the template desired by the user is drawn as a sketch and sketched with a pen-type input device.

[0007] As the sketch, an affected part diagram sketched in the past can be adopted.

[0008] The electronic medical record recorder according to the second aspect of the present invention displays the recorded medical practice performed in the past consultation, and a desired medical practice is selected from the displayed medical practice. In this case, the selected medical practice is recorded as the medical practice of the current examination. The selection is performed by a touch operation on the display screen or a click operation with a mouse.

[0009] In a preferred embodiment, the past consultation date recorded and the medical practice performed for each past consultation are displayed, and if a desired consultation date is selected, the selected consultation date is displayed. All medical treatments performed are recorded as this medical treatment.

[0010] In a preferred embodiment, when the selection is made to a specific medical practice, all the medical practices related to the specific medical practice are recorded as the current medical practice.

[0011] In a preferred embodiment, the recorded medical care actions are displayed as a list. In the list, the presence / absence of execution of the displayed medical care action is expanded for each past medical examination day.

[0012]

BEST MODE FOR CARRYING OUT THE INVENTION According to one embodiment of the present invention, a general-purpose computer, typically a personal computer or a workstation, is used for creating an electronic medical record (hereinafter, used for creating an electronic medical record). Computer is called a “hospital computer”). The hospital computer includes a pen type, for example, a liquid crystal pen tablet (hereinafter, a liquid crystal pen) as an input device of the medical record information, in addition to a keyboard and a mouse, and supports easy and efficient creation of an electronic medical record. The hospital computer has a predetermined database in which various medical-related data are stored (hereinafter, referred to as a database).
(Hospital database), and performs, for example, the following processing operation according to the instruction of the doctor who examines the patient.

FIG. 1 shows a flow of a processing operation performed by a hospital computer during a medical examination. In the figure, the hospital database 1 stores chart-related information, insurance card information, introduction letter information, and the like for each patient.

The hospital computer displays, for example, a list of patients waiting to be examined, and when a patient to be examined by a doctor is designated (step S1), the hospital computer searches the hospital database 1 and
Obtain the medical record information related file 3 of the consulted patient (S2),
Display the chart main page described below on the display
(S3). Then, according to the operation of the doctor, the past medical chart information is displayed (S4), the insurance card file 5 of the patient is obtained and the insurance card information is displayed (S5), or the medical chart information of the doctor is input. An electronic medical record creation process is performed (S6). When the creation processing is completed, specific information from the input medical record information is registered in the patient's introduction letter file 7 as introduction letter creation data (S7). Then, the various chart information input this time is registered in the corresponding various files in the chart information related file 3 (S8).

The medical record main page is a man-machine interface (MMI) for allowing a doctor to execute the processing of steps S4 to S6 on a hospital computer.
The doctor clicks on a specific location on the page with the mouse,
Alternatively, a touch operation is performed with a liquid crystal pen to cause the hospital computer to perform various processes.

FIG. 2 shows an example of the chart main page.

The chart main page has a print execution button 8
, Next patient display button 9 and chart creation end button 11
, A letter of introduction button 12, a DO input button 13,
Health insurance card button 15, image button 17, injury / illness name sheet 19, patient basic information sheet 20, visit history sheet 2
1, a finding sheet 23, a medical care action sheet 25, and an affected area diagram sheet 27. In the injury name sheet 19, a list of past injury names, treatment start dates and end dates thereof, and outcome information is developed. The visit history sheet 21 displays a list of visit histories, for example, for each of the injury names (for each medical record) displayed on the injury and disease name sheet. In the finding sheet 23, the medical treatment sheet 25, and the affected part diagram sheet 27, the findings, medical treatment, and affected part diagrams relating to the disease currently being treated (or treated in the past) are respectively developed.

The operation performed by a doctor on a hospital computer during a medical examination and the processing performed on the hospital computer in response to the operation will be described below with reference to FIG.

When referring to medical record information that is currently being treated (or has been treated in the past), the physician must use the visit history sheet 2
Touch the line of the desired reference history displayed in 1 quickly twice with a liquid crystal pen (hereinafter, twice pen touch) or double-click with a mouse. Thereby, the medical record information in the history is developed on each of the finding sheet 23, the medical care action sheet 25, and the affected area diagram sheet 25 (S4 in FIG. 1). When referring to past image information such as an X-ray photograph, the doctor touches the image button 17 once with a liquid crystal pen (hereinafter, pen touch) or clicks with a mouse. Thereby, various image information in the history is displayed. When referring to the insurance card information of the patient, the doctor touches the insurance card button 15 with a pen (or clicks with a mouse, and so on). Thereby,
The patient's insurance card information is displayed (S5 in FIG. 1).

In this way, the physician conducts a medical examination by referring to the medical chart information and insurance card information up to the present, and inputs various medical chart information at any time or at the end of the medical examination to create an electronic medical chart. . The medical record information to be input includes, for example, names of injuries and illnesses, findings (pre-existing illness, causes, major symptoms, etc.), affected part diagrams, medical treatment (treatment, prescription, examination, etc.). Less than,
An embodiment in which these are input will be described.

First, a description will be given of an embodiment in which a doctor inputs a name of a illness.

When inputting the name of the disease, the doctor touches the title bar 19 'of the disease name sheet 19 of the main chart page (see FIG. 2) twice with a pen (or double-clicks with a mouse, and so on). Then, an injury / disease name input sheet as shown in FIG. 3 is displayed on the display.

FIG. 3 shows an example of the injury name input sheet.

The injury / disease name input sheet shown in FIG. 1 includes a part sheet 28, a direction sheet 29, a prefix sheet 31,
A disease name sheet 33, a suffix sheet 35, and a disease name input result sheet 37 are displayed. The doctor selects a word or phrase displayed in advance on each of the sheets 28, 29, 31, 33, and 35 with a pen touch and inputs the name of the injury or disease, or directly inputs the name of the injury or disease name input result sheet 37 with the keyboard.

Next, an embodiment in which a doctor inputs a finding will be described.

When inputting a finding, the doctor touches the title bar 23 'of the finding sheet 23 on the main chart page (see FIG. 2) twice with a pen. Hospital computer
It is determined whether the examined patient is the first consultation or the second consultation, and the finding input sheet for the first consultation or the second consultation is displayed accordingly.

FIG. 4 shows the operation of the hospital computer when displaying the first diagnosis finding input sheet.

If the hospital computer determines that the patient is a first-time visit, the hospital computer searches the hospital database 1 and reads the patient-interview registration file 39 (step S9). It is confirmed whether or not it is (S10). If there is interview data (Ye in S10)
s) With reference to the data recorded therein, the finding template corresponding thereto is developed on the finding input sheet.
For example, various affected part names recorded in the inquiry data are counted (S11), and as a result of counting, the most affected part name is determined as the affected part of the current treatment (S12). Then, a finding template relating to the affected part of the current treatment is read from the various finding template masters 41 (S13), and each finding template is developed on the finding input sheet for the first consultation as shown in FIG.

FIG. 5 shows an example of a finding input sheet for initial examination.

The findings input sheet for the first consultation shown in the figure includes an affected part plate 43, a direction plate 45, a numerical value input panel 47, a symptom plate 49, and a stage plate 51.
The content plate 53, the comment input plate 55, and the finding input result plate 57 are developed. The diseased part plate 43 displays the name of the diseased part determined to be the part to be treated this time, and the symptom plate 49 displays a list of symptoms relating to the diseased part.

The doctor touches a specific portion on this sheet with a pen and inputs finding information. The hospital computer registers the finding information in the patient's finding registration file 42 in the hospital database 1 (S1 in FIG. 4).
5).

In the above judgment, the hospital computer determines
If it is determined that the patient has been re-examined, the following operation is performed.

FIG. 6 shows the operation of the hospital computer when displaying the reexamination finding input sheet.

The hospital computer reads the finding data from the first consultation of the patient one by one from the finding registration file 42 one by one (S16), and confirms whether or not various symptoms input in the past have been cured (S18). ). If there is a symptom that has not been cured (No in S18), a template in which the symptom is developed is developed together with the re-examination finding input sheet.

FIG. 7 shows an example of a re-examination finding input sheet.

On this sheet, a symptom list plate 59 in which the above-mentioned unhealed symptoms, their progress and comments are developed in a list is developed. For example, when inputting the progress of "tinnitus", the doctor touches the portion 60 where the progress is developed with a pen to display the progress input box 61, and checks by touching the radio button of the corresponding progress with the pen.

When the findings in the re-examination are input in this way, the hospital computer registers the finding information in the finding registration file 42 (S20 in FIG. 6). If there is no finding data to be read in step S16 (No in S17), the above-mentioned first examination finding sheet is displayed (S21).

The above is the embodiment in the case where the doctor inputs the findings. According to this embodiment, if a patient is interviewed at the time of a hospital visit or during a medical examination and the results are registered in the hospital database 1, when the findings of the re-examined patient are input, the results are based on the interview results. Since a finding input sheet is created and displayed, finding input is simplified. In this embodiment, it is possible to register the result of an inquiry to a patient who is first consulted and to develop the finding input sheet for the first consultation based on the result of the inquiry.

Next, an embodiment in which a doctor inputs (sketches) a diseased part diagram will be described.

In this embodiment, an affected part sketch template (hereinafter, referred to as an ear, eye, stomach, liver, etc.)
One or more templates are registered. When inputting the affected part map, the doctor touches a desired portion on the affected part diagram sheet 27 on the main chart page (see FIG. 2) twice with a liquid crystal pen.
When sketching based on the completed diseased part map, the doctor sets the completed diseased part map display area 27a or 27b to two.
When touching twice and sketching based on the template, pen touching is performed twice on an area (for example, area 27c) where no affected part diagram is displayed. The hospital computer performs the following processing operation.

FIG. 8 shows the processing operation of the hospital computer when the affected part diagram is input.

The hospital computer identifies the place touched twice on the affected part diagram sheet 27 (step S2).
2) The location is the filled-in diseased part map display area 27a,
27b is determined (S23). In the case where the above-mentioned location is the filled-in affected part diagram display area 27a, 27b
(Yes in S23), the selected filled-in diseased part map is developed as a draft on a diseased part drawing entry sheet described later and displayed.
(S24). If the location is the diseased part diagram display non-display area 27c (No in S23), a template relating to a part belonging to a medical department is acquired from the diseased part diagram master 63 in which the template is registered (S25) and acquired. A list of templates is created (S26) and displayed (S27).

FIG. 9 shows an example of the template list.

For example, in the examination for the ear, in this list, templates that can be used in the examination of the ear, such as the right ear template 77, the left ear template 79,... The doctor selects the desired template developed in this list and touches it with a pen. The hospital computer renders the template touched by the pen as a draft, develops it on the above-mentioned affected area diagram entry sheet, and displays it (step S28 in FIG. 8).

FIG. 10 shows an example of the affected area diagram entry sheet.

This sheet includes a sketch area 65,
Pen thickness setting box 67 and pen color setting box 69
, Eraser setting box 71 and redisplay button 73
And an end button 75 are developed. The “eraser” here is, of course, an “eraser” as found in general drawing application software (eg, paint).

In the sketch area 65, the filled-in diseased part diagram or template, which is the above-mentioned sketch, is developed. The doctor touches the drop-down button (black triangle button) of the pen thickness setting box 67 or the drop-down button of the pen color setting box 69 with a pen to set the thickness and color of the line, and completes the above. Sketch and write comments with a liquid crystal pen based on the affected part diagram or template. Further, the size of the eraser is set by touching the drop-down button of the eraser setting box 71 with a pen, and the unnecessary portion can be erased with the liquid crystal pen. When redoing the sketch, the redisplay button 73 is touched with a pen to return to the initially displayed sketch. When the sketch is completed, the end button 75 is touched with a pen.

When the end button 75 is touched by a pen (step S29 in FIG. 8), the hospital computer checks whether or not the sketch is a template selected from the template list (S30). If it is a template (Yes in S30), the affected part map after sketching and the date of the current examination are
Affected part diagram display area 2 of affected part diagram sheet 27 (see FIG. 2)
7c (S31). If the sketch is a completed affected part diagram (No in S30), it is determined whether or not the registration is new registration (S32). If the registration is new registration (Yes in S32),
If step S31 is performed and it is not a new registration, for example,
If it is a correction of the completed affected part map (No in S32),
The affected part diagram after sketching is developed in the original location of the affected part diagram sheet 27 (S33). Then, the sketched affected part diagram is registered in the chart information related file 3 in, for example, a bitmap format (S34).

The above is an embodiment in which the doctor inputs (sketches) the affected part diagram. According to this embodiment, the physician
A pen-type input device (liquid crystal pen) can be used to sketch the affected area, so sketching can be done with a feeling similar to that of a paper chart, and detailed sketching and comment input can be easily performed. Further, according to this embodiment, the doctor can make a sketch for the present examination based on the past sketch and register the sketch. Thus, the progress of healing of the affected part can be easily represented by a sketch. Further, according to this embodiment, one or a plurality of affected part sketch templates related to various parts are registered in advance, and when using the templates for the sketches, the templates related to the parts in the present examination are listed in a list format. Be expanded. The doctor selects the desired template and sketches it in the sketch. Thus, the doctor can skip the work of drawing the affected part and sketch only what is necessary, so that the sketch can be performed quickly.

In this embodiment, the doctor may be able to freely sketch without using the filled-in diseased part diagram and the template. The freely sketched image may be registered as the template.

Next, a description will be given of an embodiment in which a doctor inputs a consultation action.

When inputting a medical practice, the doctor touches the title bar 25 'of the medical practice sheet 25 on the main chart page (see FIG. 2) twice with a pen. The hospital computer performs the following processing operation.

FIG. 11 shows the operation of the hospital computer when a medical practice is input.

In the figure, the hospital database 1 has a medical practice related master 81 in which information related to various medical practices is stored. The medical practice related master 81 includes a master file of various medical practices, such as a procedure master, a procedure classification master, a unit master, an examination item master, a usage master, a site master, and so on.

When the pen is touched twice with the pen, the hospital computer obtains information for displaying the medical care action input sheet from the medical care action related master 81 (step S35),
The medical care action input sheet is displayed (S36).

FIG. 12 shows an example of the medical care action input sheet.

The medical practice sheet 83 includes, for example, a treatment input card 85, a set treatment input card 87, a surgery input card 89, an injection input card 91, a set injection input card 93, a prescription input card 95, A set prescription input card 97, an in-hospital test input card 99, an out-of-hospital test input card 101, an imaging input card 103, and an end button 105 are developed. In the figure, the treatment input sheet 85 is expanded. The doctor may enter the desired input card 85
The user touches the tabs 103 to 103 to switch the input card that has been developed, inputs various medical treatments, and touches the end button 105 to end the input.

The hospital computer develops the input card of the tab touched by the pen (S37 in FIG. 11). When the end button 105 is touched by the pen (Yes in S38), the entered medical information is stored in the medical record information related file. 3
(S39).

By the way, when inputting a medical practice, a doctor often inputs DO. As described above, the DO input is to input the same action as the previous medical practice as the current medical practice. The doctor enters the medical treatment sheet 25 on the main chart page (see FIG. 2).
The user touches the specified portion twice with the pen or touches the DO input button 13 with a pen to display a DO input sheet to be described later and perform DO input by referring to the sheet.
Hereinafter, the former will be referred to as a first DO input method and the latter as a second DO input method, and the respective DO input methods will be described.

First, referring to FIG. 13 and FIG.
Will be described.

FIG. 13 shows the configuration of the medical care action sheet 25 in detail, and FIG.

In the medical practice sheet 25, medical practices from the present consultation to the first consultation are developed in chronological order for each consultation day, for example, in order from the top (in FIG.
0.08.14 "is developed at the top.) The configuration concept of the medical care action sheet 25 is divided into three classifications of a large classification, a middle classification, and a small classification, and has a hierarchical configuration so as to include lower classifications. Examination date H1 in FIG.
Speaking of the practice in 0.08.11, the major categories are:
Comprehensive contents of the medical treatment of the day, the middle category covers all of the medical treatment in the Eustachian tube treatment (one side), nebulizer, each use of intramuscular injection, etc. Refers to each medical practice. The physician performs DO input in each of the major, middle, and small categories.

For example, in the present consultation, the doctor
All medical treatments 107 of “Eustachian tube treatment (one side)” in the medical treatment of (consultation of H10.8.11) and “Pigulin injection 200 mg 0.05 bottle” 109 of “Nebulizer”
Is DO input as the current medical practice. In this case, the doctor sets the display column 111 of “Eustachian tube treatment (one side)” and the display column 111 of “Pigulin injection 200 mg 0.05 bottle”.
Touch 3 with pen. Thereby, the medical treatment sheet 25
As shown in FIG. 15, as the medical treatment on this consultation day, all medical treatments of “Eustachian tube treatment (one side)” in the previous consultation and “Pigulin injection 200m” of “Nebulizer” were performed.
g0.05 bottle "is developed.

According to the first DO input method, the doctor only touches the pen of the desired medical practice field twice for each medical practice already displayed, that is, the DO input is performed by one operation. can do. When a plurality of medical treatments are input by DO, for example, when all of the medical treatments on the previous consultation day are input, the user only touches the date field of the medical treatment sheet 25 twice with the pen, and the medical treatments on the last consultation day are performed. All can be DO input. This eliminates the need for dragging and dropping with a mouse, and allows a user to easily input a plurality of medical practices by DO.

Next, the second DO input method will be described.

When the DO input button 13 is touched by a pen, the hospital computer displays the DO input sheet.

FIG. 16 shows an example of the DO input sheet.

[0068] The DO input sheet 100 includes
15 and a date list 117 and a DO input field 119, and an end 123 are developed. Medical practice column 1
In 15, all the medical treatments from the first consultation to the consultation on the day are developed, for example, in the above middle classification unit. Date field 1
17, the dates of the first consultation from the first consultation are developed in chronological order in order from the left, for example (in the same figure, the first consultation consultation date “H10.8.7” is developed at the leftmost). In the DO input box 119, the presence / absence of the execution of the medical practice performed in the medical practice field 115 in the past or on the day of the medical examination is developed. For example, in the past consultation, a practiced practice performed is indicated by a black circle, and a practiced practice not performed is blank. Further, in the medical examination on the day, a mark ◎ is given to a medical practice already performed, and check boxes 121a and 121b are developed for a medical practice not yet performed. At this consultation, check box 121
When the medical treatments a and 121b are performed, the check boxes 121a and 121b are touched with a pen.

The hospital computer uses the DO input sheet 10
0 is created by the operation shown in FIG. The operation will be described with reference to FIG.

First, the hospital computer develops the date of the medical examination on the day in the date column 117 of the DO input sheet 100 (step S40), acquires the medical examination date from the medical care action sheet 25 (see FIG. 13) (S41), It is confirmed whether all the medical treatments from the medical examination to the first medical examination on the day have been developed in the medical treatment column 115 (S42). If it has not been developed (No in S42), the medical practice performed in the first consultation is developed, and the consultation date acquired in step S41 is developed in the date column 117 (S43). Next, for each consultation day, past medical treatments are sequentially acquired (S
44), it is confirmed whether the acquired medical practice has been developed in the medical practice column 115 (S45), and if not, it is determined whether the acquired medical practice is a medical practice already developed in the medical practice column 115. Confirmation (S46). If the acquired medical practice is a developed medical practice (Y in S46)
es), it is assumed that the medical practice has been performed,
19 is expanded to the corresponding location of S19 (S47), otherwise (No in S46), the acquired medical practice is developed in the medical practice column 115 (S48), and The mark is developed (S49). Next, in the medical examination on the day, it is confirmed whether the developed medical practice is already performed (S50), and if it is performed (Yes in S50),
◎ is developed at the corresponding part of the DO input box 119 (S51),
If it is performed (Yes in S50), the check boxes 121a and 121b are developed for the medical treatment that is not performed (S52).

The doctor refers to the DO input sheet 100,
Check box 121 of the medical practice to be input for DO
a and 121b are pen-touched and DO input is performed, and after DO input, the end button 123 (see FIG. 16) is pen-touched.
When this is done, the hospital computer develops the medical practice of the check box touched by the pen and the medical practice in which the ◎ mark is developed on the medical practice sheet 25 as the medical practice of the day's medical examination. In addition, the doctor sets the date field 11
It is also possible to double-touch the desired consultation date displayed in 7 with a pen touch and to DO-input all the medical treatments performed on that consultation date.

According to the second DO input method, all the past various medical treatments and the presence / absence of the various medical treatments on each consultation day from the first consultation to the consultation on the day are displayed in a list. Thus, the doctor can grasp at a glance the medical treatment performed on each consultation day, and thus can easily find the desired medical treatment and input the DO.
Further, similarly to the first DO input method, in this DO input method, a plurality of medical treatments can be performed by a single pen touch operation.
O can be input.

A number of embodiments of inputting medical record information in creating an electronic medical record have been described above. In each embodiment, the doctor can create an introduction letter by pen-touching the introduction letter button 12 on the display screen of the chart main page shown in FIG. Hereinafter, an embodiment in which a doctor creates a letter of introduction using a hospital computer will be described.

FIG. 18 shows an outline of a series of operations of the hospital computer when a letter of introduction is created.

When the doctor touches the referral letter button 12 with a pen, the hospital computer first selects a referral destination medical institution (step S53), and displays a referral letter creation page described later (S54). Then, the doctor inputs information necessary for creating a referral letter (hereinafter referred to as referral letter information) (S55), and transmits it to the medical institution selected in step S53 (S5).
6).

FIG. 19 shows an example of the introduction letter creation page.

This page contains an introduction letter image 151,
An input instruction button group display sheet 153 is provided. On the display screen of this page, the doctor touches the desired type of input instruction button on the input button group display sheet 153 with a pen, and various introduction letter information (for example, [introduction purpose], [introduction reason] shown in FIG. ], [Chief complaint / illness name / current medical history], [Preference /
Allergy], ... etc.).

For example, when inputting [introduction purpose],
The doctor touches the referral purpose input button 155 shown in the same figure with a pen, or touches twice the item [referral purpose] developed in the referral letter image 151 with a pen, so that the referral purpose input sheet 157 shown in FIG. Is displayed. The doctor inputs the purpose of introduction on this sheet 157 using a keyboard. In this case, the doctor uses the template use button 16
By touching the pen 1 with a pen to display a template selection sheet 159, a desired template can be selected from the introduction letter input template (sentence) group displayed on the template selection sheet 159, and the introduction purpose can be input.

The following steps S53 to S56
The processing operation performed by the hospital computer in each of the above will be described in detail.

First, referring to FIG. 21, step S53 is performed.
The processing operation performed by the hospital computer when selecting the referral destination medical institution will be described.

The hospital computer uses the hospital database 1
Access to various information related to the referral medical institution
(Medical institution name, address, subject name, director name, e-mail address, Fax number, etc.) are obtained, a medical institution selection list is created (step S57), and it is displayed (S5).
8). Then, the doctor checks whether or not the referral this time is included in the list (S59), and if it is included (Yes in S59), a desired referral medical institution is selected from the list. (S60), the processing in step S53 is terminated, and the processing in next step S54 is executed. If it is not included (No in S59), the information of the referred medical institution is input (S61), and the information is registered in the hospital database 1 (S62). Is executed (step S54).

Next, referring to FIG. 22, step S54
The processing operation performed by the hospital computer on the introduction letter creation page display will be described.

The hospital computer uses the hospital database 1
To obtain the information (patient name, referral institution name, doctor name, etc.) of the relevant patient and the relevant referral medical institution (step S63), and transfer it to the above-mentioned referral letter image 15
1 (see FIG. 19) (S64), and the doctor selects in advance whether or not to read the chart information (S65). If the reading of the chart information is selected in advance (Yes in S65)
s), accesses the hospital database 1, and obtains the medical information of the patient (chief complaint, disease name, current medical history, preference, allergy,
Inspection findings, treatment progress, current prescription, etc.) are acquired (S6
6), and set it as the introduction letter image 151 (S6)
7). Then, the introduction letter image 151 in which each of the above types of information has been set is displayed (S68), the processing in the introduction letter creation page display is terminated, and the processing of the next introduction letter information input (step S55) is executed. .

Next, referring to FIG. 23, step S55
The processing operation performed by the hospital computer for the introduction letter information input will be described.

The hospital computer checks the input items (the above
If [Introduction purpose] or [Introduction reason] is selected (step S69), it is confirmed whether or not information on the selected item has been input (S70). If input has been completed (Y in S70)
es), the input content is set in the text input sheet (for example, the introduction purpose input sheet 157) of the selected item (S71), and is displayed (S72).
Then, the doctor edits the text of the above item (S7).
3) It is checked whether or not the editing of the item is to be ended (S74). If it is to be ended (Yes in S74), it is confirmed whether or not the introduction letter information input is to be ended (S75).

FIG. 24 shows an example of the processing operation in the text editing in step S73 in detail.

The hospital computer displays the text input sheet for the selected item and waits for input.
(Step S76), it is confirmed with the doctor whether or not to end the sentence editing (S77).

If the process is not to be terminated (No in S77), the doctor is made to select whether or not to read the registered medical record information (for example, the medical information) (S78). (Yes), it is confirmed whether reading of the medical record information is possible (S79), and if it is possible (S79).
Yes), obtain the corresponding medical information from the hospital database 1 (S80), and set it on the text input sheet.
(S81). If it is selected in step S78 that the medical record information should not be read (No in S78), a selection is made as to whether or not to use the introduction letter input template (S8).
2). If it is not used (No in S82), for example, the user enters desired introduction letter information using a keyboard and sets it in the corresponding text input sheet (S83). If it is used (Yes in S82), the corresponding It is confirmed whether the introduction letter input template can be used for the item to be executed (S8).
4). If it can be used (Yes in S84), the template text of the corresponding item is acquired from the hospital database 1 to create a list (for example, a template selection sheet 159 shown in FIG. 20) (S85) and display it. Yes (S86). Then, when a doctor-desired template is selected (S87), it is set as a text input sheet.
(S88).

In step S77, if the text editing is to be ended (Yes in S77), it is confirmed whether or not the currently edited item ([introduction purpose], [introduction reason], etc.) can be added to the template. If it is not possible (S89: No), the input sentence is displayed on the introduction letter image 151 (S90). If it is possible (Yes in S89), it is checked whether the input text has already been registered as a template (S91), and if not (No in S91), the input text is Is registered as a template (S92). It should be noted that the doctor can freely select whether to register the input text as a template.

The above is the operation in the text editing performed in step S73. When this operation is completed, as described above, the operations of steps S74 and S75 are performed, and if the input of the introduction letter information is to be ended (S7
In step 5, the process of inputting the introduction letter is terminated, and the process of transmitting the introduction letter (step S 56) is performed.

Next, referring to FIG. 25, step S56
The processing operation performed by the hospital computer in transmitting the letter of introduction will be described.

The hospital computer converts the medical record information and the contents of the letter of introduction into MML (Medical Mark-
up Language) format (step S93),
The data in the MML format is stored in, for example, a text format file (S94), and the doctor selects a transmission method.
(S95). For example, when fax transmission is selected, (S
96), the introduction letter data is converted to an image format and transmitted by fax (S97). If transmission in the rich text format is selected (Yes in S98), the data in the MML format is converted to the rich text format. (S99), and allows the doctor to select whether or not to attach an image (for example, an X-ray image in a bitmap format) (S100). If it is to be attached (Yes in S100), a list of images that can be attached is displayed.
(S101) The doctor selects a desired image (S10
2) Send an e-mail in MML (or rich text file, image is attached) (S103).

The above is an embodiment in which a doctor creates a letter of introduction using a hospital computer.

In each of the embodiments described above, the doctor can input characters by handwriting with the liquid crystal pen (or mouse), and the hospital computer recognizes what characters are input by handwriting. Can recognize characters. Hospital computer with text input area
(For example, the comment input plate shown in FIG.
When the input of the medical record information is selected in the introduction purpose input sheet 157) shown in (1), the doctor is made to select whether or not to input by handwriting. When handwriting input is selected, a handwritten character input sheet is displayed.

FIG. 26 shows an example of a handwritten character input sheet.

The hospital computer allows the user to input characters by hand with a liquid crystal pen in a predetermined cell on this sheet, and recognizes the input characters as needed or when the doctor finishes inputting characters, and displays the recognition result. . Then, if the doctor's consent is obtained, the result of character recognition is developed in the selected text input area. The hospital computer can recognize various characters such as hiragana, katakana, numbers, kanji, and alphabets.

The preferred embodiments of the present invention have been described above. However, these are merely examples for explaining the present invention, and are not intended to limit the scope of the present invention only to these embodiments. . The present invention can be implemented in other various forms. For example, the above-mentioned hospital database 1 can be made to perform a master transaction process, and the above-mentioned various information can be managed efficiently.

[Brief description of the drawings]

FIG. 1 is a flowchart showing a flow of a processing operation performed by a hospital computer during a medical examination.

FIG. 2 is a diagram showing an example of a medical chart main page.

FIG. 3 is a diagram showing an example of an injury name input sheet.

FIG. 4 is a flowchart showing the operation of the hospital computer when displaying a finding input sheet for first consultation.

FIG. 5 is a diagram showing an example of a finding input sheet for first consultation.

FIG. 6 is a flowchart showing the operation of the hospital computer when displaying a reexamination finding input sheet.

FIG. 7 is a diagram showing an example of a re-examination finding input sheet.

FIG. 8 is a flowchart showing a processing operation of the hospital computer when an affected part diagram is input.

FIG. 9 is a diagram showing an example of a template list.

FIG. 10 is a diagram showing an example of an affected area diagram entry sheet.

FIG. 11 is a flowchart showing the operation of the hospital computer when a medical practice is input.

FIG. 12 is a diagram showing an example of a medical practice input sheet.

FIG. 13 is a diagram showing the configuration of a medical care action sheet in detail.

FIG. 14 is a conceptual diagram of a configuration of a medical care action sheet.

FIG. 15 is a view of a medical care action sheet after DO input.

FIG. 16 is a flowchart showing the operation of the hospital computer when creating a DO input sheet.

FIG. 17 is a diagram showing an example of a DO input sheet.

FIG. 18 is a flowchart showing an outline of a series of operations of the hospital computer when a letter of introduction is created.

FIG. 19 is a diagram showing an example of an introduction letter creation page.

FIG. 20 is a diagram showing a state in which an introduction purpose is input.

FIG. 21 is a flowchart showing a processing operation performed in selecting a referral destination medical institution;

FIG. 22 is a flowchart showing a processing operation performed on the introduction letter creation page display.

FIG. 23 is a flowchart showing a processing operation performed when inputting the letter of introduction information.

FIG. 24 is a flowchart illustrating an example of a processing operation performed in text editing in detail.

FIG. 25 is a flowchart showing a processing operation performed in the introduction letter transmission.

FIG. 26 is a diagram illustrating an example of a handwritten character input sheet.

[Explanation of symbols]

 1 Hospital Database 13 DO Input Button 23 Finding Sheet 23 'Title Bar of Finding Sheet 25 Medical Treatment Action Sheet 25' Title Bar of Medical Practice Sheet 27 Affected Part Sheet 27a, 27b Filled Affected Part Display Area 27c No Area Displayed Area 100 DO Input sheet 121a, 121b Check box

Claims (13)

[Claims] 1. A pen-type input device, and a model of an affected part relating to various parts of a human body, wherein when a user sketches an affected part, the user-desired template is drafted and the pen-type input is performed. An electronic medical record device characterized by sketching with an apparatus. 2. The electronic medical record recording apparatus according to claim 1, wherein the sketch is an affected part diagram sketched in the past. 3. Displaying a recorded medical practice performed in a past consultation, and when a desired medical practice is selected from the displayed medical practices, the selected medical practice is performed at this time. An electronic medical record recording device characterized by recording as a medical practice of a medical examination, wherein the selection is performed by a touch operation or a mouse click operation on a display screen. 4. Displaying the recorded past consultation date and the medical treatment for each past consultation, and when the desired consultation date is selected, the examination is performed on the selected consultation date. 4. The electronic medical record recording apparatus according to claim 3, wherein all the medical treatments performed are recorded as the current medical treatments. 5. The medical treatment apparatus according to claim 3, wherein when the selection is a specific medical practice, all medical practices related to the specific medical practice are recorded as a current medical practice.
The electronic medical record recording device according to the above. 6. The electronic medical record recording apparatus according to claim 3, wherein the medical care action is displayed as a list. 7. The electronic medical record recording apparatus according to claim 4, wherein the presence / absence of execution of the displayed medical care action is expanded in the list for each of the past consultation days. 8. A patient interview result information is recorded,
The electronic medical record recording apparatus according to claim 1, wherein when a finding is recorded, a template for recording the finding information is created and displayed based on the inquiry result information. 9. The electronic medical record recording apparatus according to claim 1, wherein a character input by handwriting is recognized. 10. The electronic medical record recording apparatus according to claim 1, wherein a letter of introduction is created. 11. A step of displaying a model of an affected part with respect to various parts of a human body, a step of drawing a template selected from the displayed templates, and recording the draft with a pen-type input device. And a computer-readable recording medium on which a program for causing a computer to execute the step of recording the affected part diagram is recorded. 12. A computer, comprising: displaying a previously recorded affected part diagram that has been recorded, and rendering the selected affected part diagram as a sketch when the sketched affected part diagram is selected. 12. The program according to claim 11, further comprising a program to be executed.
The recording medium according to the above. 13. A step of displaying a recorded medical practice performed in a past medical examination, wherein the medical practice selected from the displayed medical practice is performed by a touch operation or a click operation with a mouse on a display screen. A step of recording the medical treatment as the medical treatment of the present consultation; and a computer-readable recording medium recording a program for causing the computer to execute the steps.