JP2016218643A - Electronic medical chart creation system - Google Patents

Abstract

PROBLEM TO BE SOLVED: To improve operation property in creation of an electronic medical chart of a date in which an inspection, treatment or prescription is reserved.SOLUTION: First, a date for which a schedule is desired to register (step S1) is designated, and then a reservation object patient is designated (step S2). In addition to reservation of visit to a hospital, if reservation of an inspection, treatment, or prescription is also performed (step S3: YES), reservation information suggesting an inspection, treatment, or prescription is input (step S4), and then medical chart information corresponding to a date when the patient is going to visit the hospital next time containing the reservation information is created (step S5). The created medical chart information is associated with the patient and the date when the patient is going to visit the hospital next time, and is stored (step S6). When a medical chart information input screen of the patient is displayed when the patient visits the hospital next time, the medical chart information corresponding to the date when the patient visits the hospital is acquired, and the reservation information contained in the acquired medical chart information is displayed in a prescription/treatment column on the medical chart information input screen.SELECTED DRAWING: Figure 5

Description

  The present invention relates to an electronic medical record creation system.

  In recent years, electronic medical records are becoming popular in medical facilities. The electronic medical record stores, manages and manages the information such as the patient's medical condition and prescription described in the paper medical chart in an electronic form. Electronic medical records include S (Subjective: subjective information such as patient complaints), O (Objective: objective information such as test results and test images), A (Assessment: diagnosis and evaluation by doctors), P (Plan: A SOAP column classified into four items (treatment policy / plan) and a prescription / treatment column for inputting examination, treatment, prescription, etc. for the patient are included. The contents entered in the prescription / treatment column of the electronic medical record are notified to a medical accounting apparatus (receipt computer) and used for insurance score calculation and the like.

  There is also a reservation management system that allows appointments for examinations from outside the hospital. For example, in the reservation management server that connects the electronic medical record in association with the patient ID and the examination room terminal via the hospital network, the reservation application information is received from the patient terminal, and the appointment status of the examination room is confirmed. Register the specified reservation items in association with the determined reservation date and time, and when the reservation date is reached, direct the patient's electronic medical record stored in the storage device based on the corresponding patient ID and the address of the consultation room terminal to the corresponding examination room terminal Have been proposed (see Patent Document 1).

JP 2002-334152 A

  However, conventionally, there is no linkage between the reservation function for examinations and treatments and the electronic medical record, and the reservation function is specialized only for the reservation function. The reserved patients were displayed on the patient list at the reception day. When the patient visits the examination or treatment appointment day, create chart information from the beginning (blank state) or record the examination contents and treatment contents as information and re-enter them into the electronic chart There was a need. In other words, both the contents of examination and the contents of treatment are input both at the time of reservation and at the time of creating an electronic medical record, which has been troublesome twice.

  The present invention has been made in view of the above-described problems in the prior art, and an object thereof is to improve the operability at the time of creating an electronic medical record on a day on which an examination, treatment, or prescription is reserved.

  In order to solve the above problems, the invention described in claim 1 inputs storage means for storing patient chart information for each date, and reservation information indicating an examination, treatment or prescription at the next visit for the patient. Creating medical chart information corresponding to the date of the next visit of the patient, including the inputted reservation information, and associating the created medical chart information with the date of the next visit When there is an instruction to display the medical chart information input screen of the patient to be stored in the storage means and the patient's medical chart information input screen on the display means, the medical chart information corresponding to the day of the patient visit is acquired from the storage means. And a display control means for displaying the reservation information included in the acquired medical chart information in the prescription / treatment column of the medical chart information input screen.

  According to a second aspect of the present invention, in the electronic medical record creation system according to the first aspect, the electronic medical record creation system includes a correcting means for correcting the content of the reservation information displayed in the prescription / treatment column of the medical record information input screen.

  According to a third aspect of the present invention, in the electronic medical record creation system according to the second aspect, the display control means is newly input with the contents of the reservation information in the prescription / treatment column of the medical record information input screen. Contents are displayed in an identifiable manner.

  According to a fourth aspect of the present invention, in the electronic medical record creation system according to any one of the first to third aspects, the content displayed in the prescription / treatment column of the medical record information input screen is transmitted to the medical accounting device And used for accounting, insurance score calculation or prescription issuance.

  ADVANTAGE OF THE INVENTION According to this invention, the operativity at the time of the electronic medical record preparation of the day when a test | inspection, treatment, or prescription is reserved can be improved.

It is a system configuration figure of a data management system. It is a block diagram which shows the functional structure of a data management server. It is a figure which shows the example of a data structure of medical chart information. It is a block diagram which shows the functional structure of a client terminal. It is a flowchart which shows a schedule registration process. It is a screen example of a reservation screen. It is an example of a schedule registration screen. It is an example of a reservation information input screen. It is a figure which shows the example when the medical chart information containing the treatment information and test | inspection information at the next visit is added with respect to the object patient. It is a flowchart which shows an electronic medical chart preparation process. It is a screen example of a medical chart information input screen. It is a display example when new contents are added to the prescription / treatment column on the chart information input screen.

  Embodiments of an electronic medical record creation system according to the present invention will be described below. The present invention is not limited to the illustrated example.

FIG. 1 shows a system configuration of a data management system 100 as an electronic medical record creation system.
As shown in FIG. 1, the data management system 100 includes a data management server 1, a receiving device 2, a modality 3, a client terminal 4, and a medical accounting device 5. Each device is connected to be able to perform data communication via a communication network N such as a LAN (Local Area Network).

  The data management server 1 accumulates and manages data in the medical facility such as medical record information of patients in the medical facility and image data taken by the modality 3. When the data management server 1 receives an acquisition request for various data from an external device, the data management server 1 transmits data corresponding to the acquisition request to the external device.

The reception device 2 is a computer device for performing reception registration of a patient who has visited the hospital, and includes a control unit, an operation unit, a display unit, a communication unit, a RAM, a storage unit, and the like.
The modality 3 captures an image of a region to be diagnosed by a patient as a subject, and digitally converts the captured image to generate image data of an inspection image. Modality 3 includes CR (Computed Radiography), CT (Computed Tomography), MRI (Magnetic Resonance Imaging), and the like.

The client terminal 4 is used when creating an electronic medical record, registering a schedule, referring to an examination image, etc. in a medical facility.
The medical accounting device 5 is a computer device that includes a control unit, an operation unit, a display unit, a communication unit, a RAM, a storage unit, and the like, accounting calculation (calculation of patient payment fee), insurance score calculation (for insurance claims) Receipt of receipt), issuance of prescriptions, issuance of receipts, issuance of detailed receipts, etc.

FIG. 2 shows a functional configuration of the data management server 1.
As shown in FIG. 2, the data management server 1 includes a control unit 11, an operation unit 12, a display unit 13, a communication unit 14, a RAM 15, a storage unit 16, and the like. ing.

  The control unit 11 is composed of a CPU (Central Processing Unit) and the like, and comprehensively controls the processing operation of each unit of the data management server 1. Specifically, the CPU reads out various processing programs stored in the storage unit 16 in accordance with an operation signal input from the operation unit 12 or an instruction signal received by the communication unit 14, and expands it in the RAM 15. Various processes are performed in cooperation with the program.

  The operation unit 12 includes a keyboard having cursor keys, numeric input keys, various function keys, and the like, and a pointing device such as a mouse, and controls operation signals input by keyboard operations or mouse operations. 11 is output.

  The display unit 13 includes a monitor such as an LCD (Liquid Crystal Display), and displays various screens according to instructions of a display signal input from the control unit 11.

  The communication unit 14 includes a network interface and the like, and transmits and receives data to and from an external device connected via the communication network N.

  The RAM 15 forms a work area for temporarily storing various programs, input or output data, parameters, and the like read from the storage unit 16 in various processes controlled by the control unit 11.

  The storage unit 16 includes an HDD (Hard Disk Drive), a non-volatile memory, and the like, and stores various processing programs, parameters and files necessary for executing the programs, and the like. Specifically, the storage unit 16 stores a server program P1, basic patient information D1, medical chart information D2, schedule information D3, image data D4 of examination images, examination result data D5, and the like.

  The server program P1 is a program for executing data management processing and the like in the data management server 1.

  The patient basic information D1 is information about a patient, and a patient ID, a patient name, age, sex, date of birth, and the like are associated with each patient.

  The medical chart information D2 is information indicating the progress of medical treatment of patients in a medical facility, and is created for each patient and each date. FIG. 3 shows a data configuration example of the chart information D2. The medical chart information D2 includes SOAP information, prescription information, treatment information, examination information, and the like.

  SOAP information includes S (Subjective: subjective information such as patient complaints), O (Objective: objective information such as test results and test images), A (Assessment: diagnosis and evaluation by doctors), P (Plan: treatment) This is a medical record classified for each item of (policy / plan).

The prescription information is information indicating the content of the medicine prescribed by the doctor to the patient.
The treatment information is information indicating the content of the treatment performed on the patient.
The examination information is information indicating the contents of the examination performed on the patient. The examination includes image examination such as X-ray photography, blood examination, specimen examination, biological examination and the like.

  The schedule information D3 is information related to reservations at the next visit of each patient. The schedule information D3 includes a reservation date and time, a patient name, a reservation memo, and the like. In addition, when not only the date / time reservation but also the inspection, treatment, or prescription is reserved, the schedule information D3 includes reservation information indicating the inspection, treatment, or prescription.

  The image data D4 is image data obtained by photographing a patient with the modality 3. The image data D4 is stored in a DICOM file format conforming to the DICOM standard, and is accompanied by additional information such as patient ID, examination ID, patient name, examination date, modality, and the like.

  The test result data D5 is information indicating the test result obtained by the test performed on the patient.

  When the control unit 11 receives patient basic information D1, medical chart information D2, schedule information D3, and the like from the client terminal 4 through the communication unit 14 in cooperation with the server program P1, the control unit 11 stores the received information in the storage unit 16. Let Further, when the control unit 11 receives the image data D4, the inspection result data D5, and the like from the external device through the communication unit 14, the control unit 11 stores the received data in the storage unit 16. Further, the control unit 11 provides the client terminal 4 with data related to the acquisition request in response to an acquisition request for various data from the client terminal 4.

FIG. 4 shows a functional configuration of the client terminal 4.
As shown in FIG. 4, the client terminal 4 includes a control unit 41, an operation unit 42, a display unit 43, a communication unit 44, a RAM 45, a storage unit 46, and the like. Yes.

  The control unit 41 is composed of a CPU and the like, and comprehensively controls processing operations of each unit of the client terminal 4. Specifically, the CPU reads out various processing programs stored in the storage unit 46 in accordance with an operation signal input from the operation unit 42 or an instruction signal received by the communication unit 44, expands it in the RAM 45, Various processes are performed in cooperation with the program.

  The operation unit 42 includes a keyboard having cursor keys, numeric input keys, various function keys, and the like, and a pointing device such as a mouse. The control unit 42 controls operation signals input by keyboard operation or mouse operation. 41 is output. For example, the operation unit 42 is used to create an electronic medical record when inputting reservation information indicating examination, treatment, or prescription at the next visit to the patient.

  The display unit 43 includes a monitor such as an LCD, and displays various screens according to instructions of display signals input from the control unit 41.

  The communication unit 44 is configured by a network interface or the like, and transmits / receives data to / from an external device connected via the communication network N.

  The RAM 45 forms a work area that temporarily stores various programs, input or output data, parameters, and the like read from the storage unit 46 in various processes controlled by the control unit 41.

  The storage unit 46 is configured by an HDD, a non-volatile memory, and the like, and stores various processing programs, parameters and files necessary for executing the programs, and the like. Specifically, the storage unit 46 stores a schedule registration program P2 and an electronic medical record creation program P3.

The schedule registration program P2 is a program for realizing a reservation function at the next visit of the patient.
The control unit 41 performs schedule registration for the next visit to the patient in cooperation with the schedule registration program P2. Specifically, the control unit 41 receives input of reservation information indicating an examination, treatment, or prescription at the next visit to the patient at the operation unit 42. That is, the control unit 41 and the operation unit 42 function as input means.
The control unit 41 creates the chart information D2 corresponding to the date of the next visit of the patient including the reservation information input from the operation unit 42. Then, the control unit 41 controls the communication unit 44 to associate the created chart information D2 with the date of the next visit and store it in the storage unit 16 of the data management server 1 in order to store the data in the data management server 1. To send to. That is, the control unit 41 functions as a prior medical chart creation unit.

The electronic medical record creation program P3 is a program for realizing an electronic medical record creation function.
The control unit 41 cooperates with the electronic medical record creation program P3, and when there is an instruction to display the patient's medical record information input screen on the display unit 43, the control unit 41 stores the patient's visit in the storage unit 16 of the data management server 1. The data management server 1 is inquired whether or not the chart information D2 corresponding to the current day (today) is stored.
When medical record information D2 corresponding to the patient's visit date is stored in the storage unit 16 of the data management server 1, the control unit 41 corresponds to the patient's visit date from the storage unit 16 of the data management server 1. The chart information D2 is acquired, and the reservation information included in the acquired chart information D2 is displayed in the prescription / treatment column of the chart information input screen. That is, the control unit 41 functions as a display control unit.
When the chart information D2 corresponding to the patient's visit date is not stored in the storage section 16 of the data management server 1, the control section 41 causes the display section 43 to display a blank chart information input screen.

  In the operation unit 42, the control unit 41 accepts correction of the content of the reservation information displayed in the prescription / treatment column of the chart information input screen, and reflects the corrected content in the prescription / treatment column. That is, the control unit 41 and the operation unit 42 function as correction means.

  The control unit 41 displays the contents of the reservation information and the newly input contents in an identifiable manner in the prescription / treatment column of the medical record information input screen. For example, the contents of the reservation information and the newly input contents are distinguished from each other by changing the color, or making one of the characters bold / italic / underlined.

Next, the operation in the data management system 100 will be described.
FIG. 5 is a flowchart showing a schedule registration process executed in the client terminal 4. This process is realized by software processing in cooperation with the control unit 41 and the schedule registration program P2 stored in the storage unit 46. In addition, the schedule registration process is performed, for example, at the end of the examination, but the timing to be executed is not particularly limited.

  First, when a date and time for which a schedule is to be registered (at the next visit of the patient) is designated by a user's operation from the operation unit 42 (step S1), information indicating the designated date and time is stored in the RAM 45 by the control unit 41. Is done.

  FIG. 6 shows an example of the reservation screen 431 displayed on the display unit 43. The reservation screen 431 includes a reservation date / time specification field 431a for specifying the reservation date / time. In the reservation date / time designation field 431a, the horizontal axis indicates the date, and the vertical axis indicates the time. The user designates an area corresponding to a desired date and time in the reservation date and time designation field 431a by an operation from the operation unit 42.

  For example, when an area 431b corresponding to a desired date / time is clicked in the reservation date / time designation field 431a of the reservation screen 431 shown in FIG. 6, a schedule registration screen 432 shown in FIG.

  The schedule registration screen 432 includes a date / time display field 432a, a patient designation field 432b, a today button 432c, an order input field 432d, a reservation memo input field 432e, a confirmation button 432f, and a cancel button 432g.

  In the date / time display column 432a, the date / time specified in the reservation date / time specification column 431a of the reservation screen 431 is displayed.

The patient designation field 432b is an area for designating a patient to be reserved. In the patient designation field 432b, it is possible to manually input the patient ID and the patient name directly. As characters are entered in the patient designation field 432b, patient list candidates with matching patient IDs or patient names are displayed in a pull-down menu, and candidates on the pull-down menu are dynamically narrowed down by continuing input. The user designates one of the patients from the pull-down menu by an operation from the operation unit 42. In addition, when the reservation button on the patient list is pressed or when the reservation screen is opened from the medical record information input screen, the patient is displayed in a state where the corresponding patient is automatically selected in the patient designation field 432b. .
When the today button 432c is pressed, the patient ID / patient name of the patient whose reception for the day has ended is displayed on the pull-down menu in the latest order.

  The order input field 432d is an area for registering orders such as examinations, treatments, and prescriptions at the next visit. The registration of the order is performed by selecting from candidates of order contents prepared in advance, as in the case of the input to the prescription / treatment column on the chart information input screen. When an order is registered, it is stored as a prior medical record (future medical record), and the prior medical record is displayed together with the registered order contents at the next visit of the patient.

  The reservation memo input field 432e is an area for registering a memo (notes, communication items, etc.) at the time of reservation. For example, when a reserved patient visits, the contents of the reservation memo are displayed in association with the patient in the patient list displayed on the reception device 2 installed at the reception of the medical facility. Since examinations may be carried out in advance before the examination, it is convenient if the examination reservation can be grasped at the reception stage. In addition, when the chart information input screen is opened, a dialog for displaying the contents of the reservation memo may be displayed. Note that whether or not to display the reservation memo may be selectable by setting.

The confirmation button 432f is a button for confirming the content input on the schedule registration screen 432.
The cancel button 432g is a button for canceling the contents input on the schedule registration screen 432.

  Next, when any one of a plurality of patients is designated by an operation from the operation unit 42 by the user (step S2), information indicating the designated patient is stored in the RAM 45 by the control unit 41. The

  Next, in addition to the appointment for the visit, the control unit 41 determines whether or not to make an appointment for the examination, treatment, or prescription (step S3). When making a reservation for examination, treatment, or prescription (step S3; YES), reservation information indicating the examination, treatment, or prescription is input by an operation from the operation unit 42 by the user (step S4). The input reservation information is stored in the RAM 45 by the control unit 41.

  For example, when the order input field 432d of the schedule registration screen 432 shown in FIG. 7 is clicked, the reservation information input screen 433 shown in FIG. The reservation information input screen 433 includes a prescription button 433a, a treatment button 433b, an injection button 433c, a specimen / bacteria button 433d, a biopsy button 433e, a radiation button 433f, an extraction condition input field 433g, and an order candidate display field 433h.

The prescription button 433a is pressed when ordering a prescription.
The treatment button 433b is pressed when ordering a treatment.
The injection button 433c is pressed when ordering an injection.
The specimen / bacteria button 433d is pressed when ordering a specimen / bacteria test.
The biopsy button 433e is pressed when ordering a biopsy.
The radiation button 433f is pressed when ordering a radiation image inspection.
When each of the buttons 433a to 433f is pressed, the corresponding candidate order contents are displayed in the order candidate display field 433h.

  The extraction condition input field 433g is an area for inputting a part or the like that becomes an extraction condition when extracting candidate order contents. For example, when “chest” is input in the extraction condition input field 433g and the return key is pressed, candidates for order contents corresponding to the input extraction condition are displayed in the order candidate display field 433h.

In the reservation information input screen 433 shown in FIG. 8, the radiation button 433f is pressed and “chest” is input in the extraction condition input field 433g. It is displayed in the display column 433h.
When one of the order content candidates displayed in the order candidate display column 433h is selected, the selected order content is displayed in the order input column 432d of the schedule registration screen 432 shown in FIG.

Next, based on the input reservation information, the control unit 41 creates medical chart information D2 including the reservation information and corresponding to the date of the next visit of the patient (step S5). Then, the control unit 41 associates the created medical record information D2 with the patient and the date of the next visit in order to store the data in the storage unit 16 of the data management server 1 via the communication unit 44. It is transmitted to the server 1 (step S6).
In the data management server 1, the control unit 11 stores the medical chart information D2 transmitted from the client terminal 4 in the storage unit 16 in association with the patient and the date. FIG. 9 shows an example in which medical chart information D2 including treatment information and examination information at the next visit is added to the target patient.

After step S6 or when no reservation is made for examination, treatment or prescription in step S3 (step S3; NO), the control unit 41 schedules based on the specified date and time, patient and reservation memo. Information D3 is generated. Further, when a reservation is made for an inspection, treatment, or prescription, the schedule information D3 further includes reservation information indicating the inspection, treatment, or prescription. Then, the schedule information D3 is transmitted to the data management server 1 by the control unit 41 to be stored in the storage unit 16 of the data management server 1 via the communication unit 44 (step S7).
In the data management server 1, schedule information D <b> 3 is stored in the storage unit 16 by the control unit 11.
This completes the schedule registration process.

  FIG. 10 is a flowchart showing an electronic medical record creation process executed in the client terminal 4. This process is, for example, a process performed at the time of diagnosis, and is realized by a software process in cooperation with the control chart 41 and the electronic medical record creation program P3 stored in the storage section 46.

  First, when any one of a plurality of patients is designated by the user's operation from the operation unit 42 (step S11), information indicating the designated patient is stored in the RAM 45 by the control unit 41. .

  Next, the control unit 41 determines whether or not there is an instruction to display a medical record information input screen for the designated patient (step S12).

When there is an instruction to display the medical record information input screen (step S12; YES), the control unit 41 determines whether or not there is pre-registered medical record information D2 on the day of the visit for the designated patient. Judgment is made (step S13). Specifically, whether the chart information D2 of the designated patient visit date is stored in the storage unit 16 of the data management server 1 by the control unit 41 via the communication unit 44 to the data management server 1 An inquiry is made whether or not.
In the data management server 1, based on the information (patient ID, etc.) indicating the designated patient transmitted from the client terminal 4 by the control unit 11, is the medical record information D2 of the patient's visit date stored in the storage unit 16? Is determined, and the determination result is transmitted to the client terminal 4 by the communication unit 14.

  When there is medical record information D2 on the visit day registered in advance for the designated patient (step S13; YES), the control unit 41 obtains the medical record information D2 corresponding to the visit date on the designated patient. (Step S14). Specifically, the control unit 41 sends an acquisition request for the chart information D2 on the day of visit of the designated patient via the communication unit 44 to the data management server 1 and the designated patient sent from the data management server 1 Medical record information D2 on the day of the visit is received. The received medical chart information D2 is stored in the RAM 45 by the control unit 41.

  Next, based on the chart information D2 on the day of visit of the designated patient by the control section 41, a chart information input screen in which the reservation information is reflected in the prescription / treatment column is displayed on the display section 43 (step S15). . Specifically, the control unit 41 displays reservation information (examination, treatment, prescription) included in the chart information D2 in the prescription / treatment column of the chart information input screen.

FIG. 11 shows an example of a chart information input screen 434 displayed on the display unit 43. The chart information input screen 434 includes a SOAP column 434a and a prescription / treatment column 434b.
The SOAP column 434a is an area for a doctor to input subjective information (S), objective information (O), evaluation (A), treatment policy (P), and the like.
The prescription / treatment column 434b is an area for the doctor to input examinations, treatments, prescriptions, and the like for the patient. The contents input / displayed in the prescription / treatment column 434b are transmitted to the medical accounting device 5 and used for accounting calculation, insurance score calculation, or issuance of a prescription. In the medical record information input screen 434 shown in FIG. 11, the contents 434c of the reservation information registered in advance are displayed in the prescription / treatment column 434b.

  Here, when the content of the prescription / treatment column on the medical record information input screen is modified by the user's operation from the operation unit 42 (step S16; YES), the control unit 41 controls the prescription / treatment on the medical record information input screen. In the treatment column, the contents of the reservation information and the newly input contents are displayed in an identifiable manner (step S17).

  FIG. 12 shows a display example when the newly input content 434d is added to the prescription / treatment column 434b on the medical record information input screen 434 shown in FIG. In the prescription / treatment column 434b, the reservation information content 434c registered in advance and the newly input content 434d are displayed in different colors, such as being displayed in different colors.

  In step S13, when there is no pre-registered medical record information D2 on the day of visit for the designated patient (step S13; NO), the control unit 41 displays a blank medical record information input screen on the display unit 43. (Step S18).

In step S16, when the contents of the prescription / treatment column of the medical record information input screen are not corrected (step S16; NO), after step S17 or step S18, the operation from the operation unit 42 of the user causes the medical record information input screen to The chart information D2 is input as necessary (step S19). The chart information D2 created by inputting new contents or modifying the contents is stored in the RAM 45 by the control unit 41. When confirmation of the medical chart information D2 is instructed by an operation from the operation unit 42 of the user, the control unit 41 is confirmed to be stored in the storage unit 16 of the data management server 1 via the communication unit 44. The medical chart information D2 of the contents is associated with the patient and the date and transmitted to the data management server 1 (step S20).
In the data management server 1, when the chart information D <b> 2 is received from the client terminal 4 by the communication unit 14, the received chart information D <b> 2 is stored in the storage unit 16 in association with the patient and date by the control unit 11. The Here, when the medical chart information D2 is stored in advance, the medical chart information received from the client terminal 4 (including the contents corrected and added) is used instead of the medical chart information D2 stored in advance. D2 is stored in the storage unit 16.

Next, the examination information, treatment information, and prescription information displayed in the prescription / treatment column of the medical record information input screen are transmitted to the medical accounting device 5 by the control unit 41 via the communication unit 44 (step S21). .
The medical accounting device 5 performs accounting calculation, insurance score calculation, prescription issuance, and the like based on the examination information, treatment information, and prescription information received from the client terminal 4.
This completes the electronic medical record creation process.

  As described above, according to the present embodiment, by creating the chart information D2 including the reservation information indicating the examination, treatment, or prescription in association with the date of the next visit of the patient, Reservation information is displayed in the prescription / treatment column of the medical record information input screen on the day of the visit, so there is no need to enter the contents of the examination, treatment, or prescription when creating the electronic medical record, reducing the burden of creating the electronic medical record on the visit day The Therefore, it is possible to improve the operability at the time of creating the electronic medical record on the day when the examination, treatment or prescription is reserved.

  In addition, when the content of the reservation information displayed in the prescription / treatment column needs to be corrected, the content of the reservation information can be appropriately corrected. Also, at that time, the contents of the reservation information and the newly entered contents are displayed in an identifiable manner in the prescription / treatment column of the chart information input screen, so the contents registered in advance and added later・ Understand the revised contents.

  Note that the description in the above embodiment is an example of an electronic medical record creation system according to the present invention, and the present invention is not limited to this. The detailed configuration and detailed operation of each device constituting the system can be changed as appropriate without departing from the spirit of the present invention.

  For example, in the above embodiment, the case where the patient's medical record information D2 is stored and managed in the data management server 1 has been described. However, the storage location of the medical record information D2 is outside the medical facility such as on a cloud server. Alternatively, it may be inside the client terminal 4 used for creating the electronic medical record.

  In the above embodiment, examination information, treatment information, and prescription information are transmitted from the client terminal 4 to the medical accounting apparatus 5. However, these pieces of information are transmitted from the data management server 1 to the medical accounting apparatus 5. It is also good to do.

  In addition, treatment / prescription candidates related to each examination are registered in advance, and when the pre-registered examination contents are displayed in the prescription / treatment column of the chart information input screen, It is good also as displaying the candidate of prescription.

  In the above description, an example in which an HDD or a non-volatile memory is used as a computer-readable medium storing a program for executing each process is disclosed, but the present invention is not limited to this example. As another computer-readable medium, a portable recording medium such as a CD-ROM can be applied. A carrier wave may be applied as a medium for providing program data via a communication line.

DESCRIPTION OF SYMBOLS 1 Data management server 4 Client terminal 5 Medical accounting apparatus 11 Control part 16 Storage part 41 Control part 42 Operation part 43 Display part 46 Storage part 100 Data management system 431 Reservation screen 432 Schedule registration screen 432a Date display column 432b Patient designation field 432d Order Input field 433 Reservation information input screen 434 Medical record information input screen 434a SOAP field 434b Prescription / treatment field D2 Medical record information D3 Schedule information N Communication network P1 Server program P2 Schedule registration program P3 Electronic medical record creation program

Claims (4)

Storage means for storing patient chart information by date;
Input means for inputting reservation information indicating examination, treatment or prescription at the next visit to the patient;
Create chart information corresponding to the date of the next visit of the patient, including the inputted reservation information, and store the created chart information in association with the date of the next visit in the storage means Chart creation means,
When there is an instruction to display the patient's chart information input screen on the display means, the chart information corresponding to the patient's visit date is acquired from the storage means, and the reservation included in the acquired chart information Display control means for displaying information in the prescription / treatment column of the chart information input screen;
An electronic medical record creation system.   The electronic medical record creation system according to claim 1, further comprising a correcting unit for correcting the content of the reservation information displayed in the prescription / treatment column of the medical record information input screen.   3. The electronic medical record creation system according to claim 2, wherein the display control unit displays the contents of the reservation information and the newly input contents in an identifiable manner in the prescription / treatment column of the medical record information input screen.   The content displayed in the prescription / treatment column of the medical record information input screen is transmitted to the medical accounting device and used for accounting calculation, insurance score calculation, or prescription issuance. Electronic medical record creation system.

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