JP2018151797A - Information processing device, medical audit device, and program - Google Patents

Abstract

PROBLEM TO BE SOLVED: To determine whether or not the performance of a medical practice is recorded in a performance recording document that does not have as an attribute a performance recording document type associated with a medical practice type as an attribute of the medical practice in advance.SOLUTION: In a case where a third performance recording document having as an attribute a third performance recording document type is not registered, when hospital information which is recorded in a first specific region of a first performance recording document having as an attribute a first performance recording document type and hospital information which is recorded in a second specific region of a second performance recording document having as an attribute a second performance recording document type correspond with each other, processing is performed on the assumption that the third performance recording document has been registered.SELECTED DRAWING: Figure 1

Description

  The present invention relates to an information processing apparatus, a medical audit apparatus, and a program.

  There is a system for recording and storing an execution of a medical practice in an implementation record document having as an attribute an implementation record document type associated in advance with the medical practice type that is the type of the medical practice.

  Patent Document 1 discloses a system that supports creation of medical plans and medical records by doctors and nurses.

JP 2001-52073 A

  By the way, there is a case where an implementation of a certain medical practice is recorded in an implementation record document that does not have an implementation record document type associated in advance with the medical practice type that is the type of the medical practice as an attribute. In this case, there is a record that the medical practice has been performed, but there is actually no implementation record document having as an attribute the implementation record document type previously associated with the medical practice type of the medical practice. For example, there may be a problem when auditing medical information.

  It is an object of the present invention to determine whether or not an implementation of a medical practice is recorded in an implementation record document that does not have an implementation record document type previously associated with the medical practice type as an attribute of the medical practice. There is in doing so.

  The invention according to claim 1 has, as an attribute, a first implementation record document type pre-associated with a first medical practice type as an attribute of the first medical practice, and the implementation of the first medical practice is recorded. Registering the first implementation record document, having as an attribute the second implementation record document type previously associated with the second medical practice type as an attribute of the second medical practice, and recording the implementation of the second medical practice, Registration means for registering a second execution record document created in accordance with the presence of the first execution record document, and a third execution record document type previously associated with a third medical action type as an attribute of the third medical action When the third implementation record document having the attribute is not registered by the registration means, the hospital information recorded in the first specific area of the first implementation record document and the second specification of the second implementation record document Hospital information recorded in the area And a processing unit that processes the third implementation record document as a document registered by the registration unit, and the third implementation record document is the first implementation record document. The information processing apparatus is a document that is created in accordance with the presence of the information and that is assumed to record information related to the recording contents of the second implementation record document in which the hospital information has the correspondence relationship.

  The invention according to claim 2 is a control means for causing the processing means to display an execution record document on a display means, and the control means includes a display mode of the first execution record document and the second execution record document, The information processing apparatus according to claim 1, wherein a display mode of the third working record document processed as a registered document is different.

  According to a third aspect of the present invention, when the third execution record document processed as the document registered by the processing means is selected, the control means selects the first execution record document and the second execution record. 3. The information processing according to claim 2, wherein a document is displayed on the display means, and the first specific area and the second specific area are displayed on the display means separately from other areas. Device.

  According to a fourth aspect of the present invention, the first implementation record document is a document created in the first hospital and sent from the first hospital to the second hospital, and the second implementation record document is the first implementation document An implementation record of the second medical practice performed at the second hospital in accordance with an implementation record document is a document sent to the first hospital and the hospital information having the correspondence relationship is the first hospital The information processing apparatus according to any one of claims 1 to 3, wherein the information processing apparatus is information indicating information.

  According to a fifth aspect of the present invention, the first implementation record document is a document in which first medical information regarding medical treatment of the patient obtained by treating a patient at the first hospital is recorded. The second implementation record document is a document in which second medical information regarding the medical treatment of the patient obtained by treating the patient at the second hospital is recorded, and the third implementation record document is the second medical treatment record. 5. The information processing apparatus according to claim 4, wherein the information is a document in which information related to at least the first medical information is recorded.

  The invention according to claim 6 has, as an attribute, a fourth implementation record document type previously associated with a fourth medical practice type as an attribute of the fourth medical practice, and the implementation of the fourth medical practice is recorded. Registering means for registering the fourth implementation record document, and the third implementation record document type pre-associated with the third medical practice type as the attribute of the third medical practice as attributes, and medical information relating to the medical treatment of the patient is recorded In the case where the third implementation record document that is supposed to be registered is not registered by the registration unit, when information indicating a doctor's findings for the patient is recorded in a specific area of the fourth implementation record document, An information processing apparatus comprising: processing means for processing the third execution record document as a document registered by the registration means.

  According to a seventh aspect of the present invention, the processing means is control means for displaying an execution record document on a display means, and the control means is processed as a display form of the fourth execution record document and a registered document. The information processing apparatus according to claim 6, wherein a display mode of the third execution record document is different.

  According to an eighth aspect of the present invention, when the third execution record document is selected, the control means displays the fourth execution record document on the display means, and distinguishes the specific area from other areas. The information processing apparatus according to claim 7, wherein the information processing apparatus is displayed on the display unit.

  In the invention according to claim 9, the fourth implementation record document is a document for reporting to the first hospital that the patient introduced from the first hospital to the second hospital has visited the second hospital. The third implementation record document is a document in which the medical information regarding the medical care of the patient obtained by treating the patient at the second hospital is recorded. The information processing apparatus according to claim 8.

  The invention according to claim 10 has, as an attribute, a first implementation record document type previously associated with a first medical practice type as an attribute of the first medical practice, and the implementation of the first medical practice is recorded. Registering the first implementation record document, having as an attribute the second implementation record document type previously associated with the second medical practice type as an attribute of the second medical practice, and recording the implementation of the second medical practice, Registration means for registering a second execution record document created in accordance with the presence of the first execution record document, and a third execution record document type previously associated with a third medical action type as an attribute of the third medical action When the third implementation record document having the attribute is not recorded by the registration means, the hospital information recorded in the first specific area of the first implementation record document and the second specification of the second implementation record document Hospital recorded in the area If there is a correspondence relationship, the processing means for processing the third execution record document as a document registered by the registration means, and the presence or absence of registration of the execution record document when medical information is audited Display control means for displaying information on the display means as information used for the audit, the third implementation record document is created in accordance with the presence of the first implementation record document, and the hospital information is The medical auditing apparatus is a document on which information related to the recording content of the second execution record document having the correspondence relationship is assumed to be recorded.

  The invention described in claim 11 has, as an attribute, a fourth implementation record document type previously associated with a fourth medical practice type as an attribute of the fourth medical practice, and the implementation of the fourth medical practice is recorded. Registering means for registering the fourth implementation record document, and the third implementation record document type pre-associated with the third medical practice type as the attribute of the third medical practice as attributes, and medical information relating to the medical treatment of the patient is recorded In the case where the third implementation record document that is supposed to be registered is not registered by the registration unit, when information indicating a doctor's findings for the patient is recorded in a specific area of the fourth implementation record document, When the third implementation record document is processed as a document registered by the registration unit and medical information is audited, information on the presence / absence of registration of the implementation record document is included in the audit. Display control means for displaying on the display means as the information needed is an apparatus for medical audit with.

  According to a twelfth aspect of the present invention, the computer has, as an attribute, a first implementation record document type pre-associated with a first medical practice type as an attribute of the first medical practice, and the implementation of the first medical practice is performed. The recorded first implementation record document is registered, and has the second implementation record document type previously associated with the second medical practice type as the attribute of the second medical practice as an attribute. Registration means for registering a second action record document recorded and created in response to the presence of the first action record document, a third action record pre-associated with a third medical action type as an attribute of the third medical action When the third implementation record document having the document type as an attribute is not registered by the registration means, the hospital information recorded in the first specific area of the first implementation record document and the second implementation record document 2 in specific areas When the recorded hospital information has a correspondence relationship, the third execution record document is caused to function as a processing unit that processes the document as a document registered by the registration unit. It is a program that is created in response to the presence of one implementation record document and is a document that is assumed to record information related to the recording contents of the second implementation record document in which the hospital information has the correspondence.

  The invention according to claim 13 has a computer as an attribute of a fourth implementation record document type pre-associated with a fourth medical practice type as an attribute of the fourth medical practice, and the implementation of the fourth medical practice is performed. Registering means for registering the recorded fourth execution record document, having a third execution record type associated in advance with a third medical action type as an attribute of the third medical action as an attribute, and medical information relating to the medical treatment of the patient Is recorded in a specific area of the fourth implementation record document when the third implementation record document assumed to be recorded is not registered by the registration means. In this case, the program causes the third implementation record document to function as a processing unit that processes the document as a document registered by the registration unit.

  According to the first, sixth, twelfth, and thirteenth aspects of the present invention, implementation of a medical practice does not have an implementation record document type that is previously associated with a medical practice type as an attribute of the medical practice as an attribute. It can be determined whether or not it is recorded in the document.

  According to the second and seventh aspects of the invention, compared with the case where the display mode is not changed, it becomes easier for the operator to determine whether or not the execution record document is actually registered by the registration means.

  According to the third and eighth aspects of the present invention, it is easier for the operator to grasp the contents recorded in the specific area compared to the case where the specific area is displayed without being distinguished from other areas.

  According to invention of Claim 4,5,9, implementation of medical practice was previously linked | related with the medical practice type as an attribute of the said medical practice targeting the implementation record document sent between several hospitals It can be determined whether or not the record is recorded in an execution record document that does not have the execution record document type as an attribute.

  According to the tenth and eleventh aspects of the present invention, when medical information is audited, information provided for the audit is provided.

It is a figure which shows an example of the medical information management system which concerns on this embodiment. It is a figure which shows an example of the medical information management apparatus which concerns on this embodiment. It is a figure which shows a terminal device. It is a figure which shows an example of a patient management table. It is a figure which shows an example of a document kind definition table. It is a figure which shows an example of an analysis area definition table. It is a figure which shows an example of a document management table. It is a figure which shows an implementation record document typically. It is a figure which shows an implementation record document typically. It is a flowchart which shows the registration process of an implementation record document. It is a flowchart which shows a registration status evaluation process. It is a flowchart which shows a document analysis process. It is a flowchart which shows a document analysis process. It is a flowchart which shows a display process. It is a flowchart which shows a display process. It is a figure which shows an example of a registration status screen. It is a figure which shows an example of a registration status screen. It is a figure which shows an example of the image showing an implementation record document. It is a figure which shows an example of an unregistered message. It is a figure which shows an example of the image showing a related implementation record document. It is a figure which shows an example of the image showing a related implementation record document.

  A medical information management system as an information processing system according to an embodiment of the present invention will be described with reference to FIG. FIG. 1 shows an example of a medical information management system according to the present embodiment.

  The medical information management system according to the present embodiment is a system that performs registration, management, and the like of an implementation record document in which an implementation of a medical practice is recorded. As an example, the medical information management apparatus 10 as an information processing apparatus, 1 or A plurality of terminal devices 12. The medical information management device 10 and the terminal device 12 have a function of communicating with each other via a communication path N such as a network, for example. The medical information management system may include other devices such as a server.

  The medical information management apparatus 10 has a function of registering, managing, and the like of an execution record document in which medical practice is recorded. The registration instruction for the execution record document may be given by the medical information management device 10 or the terminal device 12. Moreover, the data of the implementation record document may be stored in the medical information management apparatus 10, or may be transmitted to the terminal apparatus 12 and stored in the terminal apparatus 12, or transmitted to another apparatus such as a server. It may be stored in the other device. Further, the implementation record document may be displayed on the medical information management device 10, the terminal device 12, other devices, or the like.

  The terminal device 12 is a device such as a personal computer (PC), a tablet PC, a smartphone, or a mobile phone.

  Here, the medical practice and the implementation record document will be described. A medical practice is an action performed by a medical worker such as a doctor or nurse, for example, registration of a referral letter of a patient from another hospital, return of the referral letter, reporting of a patient's visit, in-patient treatment It is an act of making a plan, operation record, operation site check, etc. Usually, when a medical practice is performed in a hospital, the implementation of the medical practice is recorded in an implementation record document by a worker such as a healthcare worker. For example, an implementation record document as a sheet or digitized implementation record document data is used, and the implementation of a medical practice is recorded in the implementation record document. The implementation record document is a document related to medical practice, such as a letter of return for a referral letter, a visit report, a hospitalization plan, a surgical record, a surgical site check, and the like.

  In the present embodiment, a medical practice type that is an attribute (for example, type) of a medical practice and an implementation record document type that is an attribute (for example, a type) of an implementation record document in which the implementation of the medical practice is to be recorded. Associated. Usually, when a medical practice (for example, “surgery record”) is performed by a worker such as a medical worker, an implementation record document associated in advance with a medical practice type (for example, “surgery record”) that is an attribute of the medical practice. The implementation of the medical practice is recorded in the implementation record document having the species (for example, “surgery record”) as an attribute. In the above example, the operation record is described in the operation record. For example, an operator such as a medical worker describes the implementation of a medical practice in an implementation record document as a form, or describes the implementation of a medical practice in data of the implementation record document.

  In addition, each implementation record document may be created according to a predetermined order. For example, in a medical field such as community medicine, a patient is introduced from one hospital (first hospital) to another hospital (second hospital), and a medical practice is performed on the patient at the second hospital. is there. In such a case, the medical staff of the referral primary hospital usually sends an implementation record document “introduction letter” to the referral of the second hospital, and then the medical care of the referral of the second hospital. The worker sends an implementation record document “thank you letter” to the referral primary hospital. In addition, an implementation record document such as a “progress report” of the introduced patient is created at the second hospital of the referral destination, and an implementation record document such as the “progress report” is received from the second hospital of the referral destination. Sent to the referral hospital.

  On the other hand, an implementation of a medical practice does not have, as an attribute, an implementation record document type previously associated with a medical practice type as an attribute of the medical practice (for example, an implementation previously associated with the medical practice type There are cases in which an execution record document having an execution record document type different from the record document type as an attribute or an execution record document having no execution record document type as an attribute in the first place is recorded. Hereinafter, this point will be described in detail with a specific example.

  As an example, medical practice types A, B, C, and D and execution record document types A, B, C, and D are described as examples.

  The medical practice type A is a medical practice type of “introducing a patient to another hospital”. The implementation record document type A is an implementation record document type “introduction letter from another hospital”, and is an implementation record document type associated with the medical practice type A in advance. The implementation record document A (introduction letter) having the implementation record document type A as an attribute records the implementation of the medical practice A having the medical practice type A as an attribute. The referral letter is a document created at the referral source hospital and sent to the referral destination hospital when the patient is introduced from the referral source hospital to the referral destination hospital. In the referral letter, for example, hospital information for identifying the referral hospital (for example, hospital name, doctor name, address, telephone number, etc.), hospital information for identifying the referral hospital, and patient identification Patient identification information, etc. are recorded. Usually, in the referral letter, medical information (for example, the medical result of hypertension) indicating the result of medical care (diagnosis, examination, treatment, etc.) performed on the patient at the referral source hospital is recorded. Of course, the medical care information is not recorded on the referral letter, but a medical care information provision form (described later) in which the medical care information is recorded is created at the referral source hospital. It may be sent to the referral hospital. The hospital information for identifying the referral source hospital is information indicating the sender of the referral letter, and is usually recorded in a specific area of the referral letter.

  The medical practice type B is a medical practice type of “providing medical information”. The implementation record document type B is an implementation record document type called “medical information provision form”, and is an implementation record document type associated with the medical practice type B in advance. The implementation record document B (medical care information provision form) having the implementation record document type B as an attribute records the implementation of the medical practice B having the medical practice type B as an attribute. The medical information provision form is a document that is created at the referral source hospital when the patient is introduced from the referral source hospital to the referral destination hospital and is sent to the referral destination hospital. The medical information provision form includes, for example, identification information for identifying the referral hospital, hospital information for identifying the referral hospital, patient identification information for identifying the patient, and patient at the referral hospital The medical information indicating the results of the medical care performed on (for example, the medical results of high blood pressure and the medical care of colds) is recorded. The hospital information for identifying the introduction destination hospital is information indicating the destination of the medical information provision form, and is usually recorded in a specific area of the medical information provision form.

  The medical practice type C is a medical practice type called “visit report”. The implementation record document type C is an implementation record document type called “visit report” and is an implementation record document type associated with the medical practice type C in advance. The implementation record document C (visit report) having the implementation record document type C as an attribute records the implementation of the medical practice C having the medical practice type C as an attribute. The Visit Report is a document for reporting to the referral hospital that the patient referred from the referral hospital has visited the referral hospital, and is created at the referral hospital. This document is sent from the hospital to the referral hospital.

  The medical practice type D is a medical practice type called “test treatment result report”. The implementation record document type D is an implementation record document type called “test treatment result report”, and is an implementation record document type associated with the medical practice type D in advance. The implementation record document D (test / treatment result report) having the implementation record document type D as an attribute records the implementation of the medical practice D having the medical practice type D as an attribute. The test treatment result report is a document that is created at the referral hospital where the patient was introduced and sent to the referral hospital. In the examination treatment result report, for example, a medical treatment result (for example, a result of examination or treatment relating to high blood pressure) at a referral destination with respect to a medical treatment result (for example, a medical treatment result of hypertension) in the referral source hospital is recorded.

  Here, a case where a patient is introduced from the first hospital to the second hospital will be described. In this case, an introduction letter is created at the first hospital and sent to the second hospital. In the referral letter, the hospital information of the first hospital indicating the sender is recorded. In the referral letter, medical information indicating the result of medical care performed on the patient at the first hospital (for example, the medical result of hypertension) is recorded. Of course, a medical information provision form may be created at the first hospital, and the medical information provision form may be sent from the first hospital to the second hospital together with a letter of introduction. Here, it is assumed that medical information is recorded in the referral letter, and the medical information provision form is not separately sent from the first hospital to the second hospital. In the second hospital, the referral letter sent from the first hospital is registered in the medical information management system. When the patient introduced by the letter of introduction visits the second hospital, the second hospital creates a visit report to report to the first hospital that the patient has visited the second hospital. Is sent from the second hospital to the first hospital. In the second hospital, the visit report is registered in the medical information management system. In addition, in the second hospital, the patient is treated, and the medical results in the second hospital (for example, the results of examinations and treatments related to hypertension) with respect to the medical results in the first hospital (for example, the results of medical treatment for hypertension). In order to report to the first hospital, a test treatment result report in which medical treatment results in the second hospital are recorded is created. The test treatment result report is sent from the second hospital to the first hospital. In the second hospital, a test treatment result report is registered. In addition, a medical information provision form may be created at the second hospital and sent from the second hospital to the first hospital. In this case, the medical care information provision form includes, for example, medical information indicating medical results at the first hospital (for example, high blood pressure medical results), and medical results at the second hospital (for example, high blood pressure medical results and cold medical result). Is recorded. The medical information provision form records hospital information of the first hospital indicating the destination. In this way, a medical information provision form sent from the second hospital to the first hospital is created and registered in the second hospital according to the presence of the referral letter sent from the first hospital to the second hospital There is.

  In the above example, for example, the medical treatment information report may be sent from the second hospital to the first hospital together with the test treatment result report without creating the test treatment result report itself. For example, in the medical information provision form, a test result report is recorded in addition to the medical information, and the medical information provision form also serves as a test treatment result report, or the medical information itself recorded in the medical information provision form is the test treatment result. By serving as a report, the medical care information provision document may also serve as a test treatment result report. Further, when the medical information provision form is sent to the first hospital, the hospital information of the first hospital is recorded in a specific area of the medical information provision form. The hospital information of the first hospital in this case corresponds to information indicating the destination of the medical information provision form. If the test treatment result report is not created, the test treatment result report is not registered in the medical information management system.

  In addition, the second hospital does not produce a test and treatment result report itself, and the doctor's findings corresponding to the test and treatment result report are recorded in a specific area of the visit report. In some cases, it is sent from two hospitals to the first hospital. In this case, the test treatment result report is not registered in the medical information management system.

  As described above, in medical practice, the implementation of all medical practices is to be recorded as a regular implementation record document to be recorded (an implementation record document type previously associated with a medical practice type as an attribute of the medical practice). The record of the medical record is not necessarily recorded as an attribute), and at least a part of the medical practice has an implementation record document type associated with the medical practice type as the attribute of the medical practice as an attribute. May not be recorded in the implementation record document.

  The implementation record document is used for medical audits, for example. In the audit, for example, an audit for evaluating whether or not a medical practice is properly performed, an audit for evaluating whether or not a predetermined medical practice is actually performed, and a predetermined order Audits to evaluate whether or not each medical practice has been implemented are conducted. The audit is performed by an auditor, for example. For example, when there is an entity (for example, paper or data) of an implementation record document in which an implementation of a certain medical practice is recorded, it is determined that the medical practice has actually been performed. As described above, the existence of the entity of the implementation record document may prove that the medical practice has been appropriately implemented. At the time of an audit, for example, information indicating the presence or absence of the actual record document or the actual record document itself is displayed on the display device, and the auditor performs an audit based on the information displayed there. In order to evaluate whether or not the audit has been properly performed, an audit may be performed on an audit performed by an auditor. Even in this case, the audit may be performed by confirming the existence of the entity of the execution record document.

  Hereinafter, each device included in the medical information management system according to the present embodiment will be described in detail.

  The medical information management apparatus 10 will be described in detail with reference to FIG. FIG. 2 shows the configuration of the medical information management apparatus 10.

  The communication unit 14 is a communication interface, and has a function of transmitting data to another device and a function of receiving data from another device. The communication unit 14 may be a communication interface having a wireless communication function or a communication interface having a wired communication function.

  The storage unit 16 is a storage device such as a hard disk or a memory, and stores various programs, various data, address information of an external device (for example, address information of the terminal device 12), and the like. The storage unit 16 includes a patient information storage unit 18, a document type definition storage unit 20, an analysis area information storage unit 22, and a document storage unit 24.

  The patient information storage unit 18 stores patient information for identifying a patient. The patient information includes information such as patient ID, patient name, sex, date of birth, hospitalization date, and the like.

  The document type definition storage unit 20 stores document type definition information. The document type definition information is information indicating each execution record document type as an attribute of each execution record document classified according to a format or the like. For example, the medical action type as the attribute of the medical action and the implementation of the medical action This is information indicating an association with an implementation record document type as an attribute of the implementation record document to be recorded. For example, the document type definition information is created in advance and stored in the document type definition storage unit 20.

  The analysis area information storage unit 22 stores analysis area information. The analysis area information is information (for example, coordinate information) indicating an analysis area (an area corresponding to a specific area) in the execution record document determined for each execution record document type. As will be described later, a character string is extracted from an analysis area of an execution record document having a specific execution record document type as an attribute, and the character string is analyzed. The analysis area information is created in advance and stored in the analysis area information storage unit 22, for example.

  The document storage unit 24 stores data of an implementation record document in which an implementation of a medical practice is recorded (data as an entity of the implementation record document). The data of the implementation record document is created by the document registration unit 26 described later. The data of the implementation record document itself may be stored in another storage device (for example, a server) without being stored in the document storage unit 24.

  The document storage unit 24 stores management information for managing the execution record document. The management information includes, for example, patient information such as a patient ID, and information indicating an implementation record document (or an implementation record document type as an attribute of the implementation record document) in which an implementation of a medical practice performed on the patient is recorded. Information indicating the association between and. In addition, the management information may include information indicating the location where the data as the entity of the implementation record document is stored (for example, address information such as a URL indicating the storage location of the data), etc. Good. For example, management information is updated each time an implementation record document is registered in the medical information management system.

  The document registration unit 26 has a function of registering an execution record document. For example, when registering an implementation record document, the document registration unit 26 causes the document storage unit 24 to store management information of the implementation record document in which the implementation of the medical practice is recorded. Thereby, the execution record document is registered in the medical information management system.

  Further, the document registration unit 26 has a function of creating data of an implementation record document. The data of the execution record document is stored in the document storage unit 24. For example, in the case where the implementation record document itself is composed of paper, when the implementation record document as the paper is read by the scanner at the time of registration of the implementation record document, the document registration unit 26 is based on the result of the reading. Then, data (for example, image data) of the execution record document is created. The implementation record document as a sheet includes, for example, patient identification information (for example, patient name and patient ID) for identifying a patient, information indicating the implementation record document type of the implementation record document, etc., as code information (for example, 1 (Dimensional barcode, two-dimensional barcode, etc.). When the execution record document as the paper is read by the scanner, the code information is also read. The document registration unit 26 analyzes the code information to acquire patient identification information, information indicating the execution record document type, and the like, and associates them with the execution record document data as management information of the execution record document. The management information is stored in the document storage unit 24. Of course, digitized data may be used without using the implementation record document as a sheet. The document registration unit 26 may acquire information indicating patient identification information and an execution record document type without using the code information. For example, patient identification information may be input by an operator, or may be input to the medical information management apparatus 10 from another device.

  The document registration unit 26 may edit the management information in response to an instruction to edit the management information. For example, after an execution record document is registered, when an instruction to change the association of each information included in the management information is given, the document registration unit 26 edits the management information according to the instruction.

  Hereinafter, an execution record document registered in the presence of data and paper as an entity will be referred to as an “entity registration document (registered document)”, and this registration will be referred to as an “entity registration”. For example, in the case where data as an entity of an implementation record document exists and is stored in the document storage unit 24 and management information of the implementation record document is stored in the document storage unit 24, the implementation record document is stored in the medical information management system. That is, the execution record document corresponds to the entity registration document.

  In addition, an implementation of a certain medical practice may be recorded in an implementation record document that does not have an implementation record document type associated in advance with a medical practice type that is an attribute of the medical practice. In this case, an implementation record document having the implementation record document type as an attribute may be regarded as registered in the medical information management system according to an analysis result of the document analysis unit 30 described later. That is, even an implementation record document that does not have actual data or paper may be regarded as being registered in the medical information management system. Hereinafter, an implementation record document that is considered to be registered in the medical information management system without any actual data or paper is referred to as “deemed registration document”, and this registration is referred to as “deemed registration”. I will do it.

  The registration status evaluation unit 28 has a function of evaluating the registration status of the implementation record document for each patient. For example, the registration status evaluation unit 28 determines whether or not a specific implementation record document is registered in the medical information management system.

  When the registration status evaluation unit 28 determines that the specific implementation record document is unregistered, the document analysis unit 30 determines that another implementation record document (hereinafter referred to as “related implementation record document”) related to the specific implementation record document. Is recorded), and based on the analysis result, it is determined whether or not the specific implementation record document is regarded as a deemed registered document. Specifically, the document analysis unit 30 acquires the analysis area information about the related execution record document from the analysis area information storage unit 22, and performs image analysis or natural language analysis on the analysis area in the related execution record document. And based on the analysis result, it is determined whether or not the specific execution record document corresponds to the deemed registered document. The analysis processing by the document analysis unit 30 will be described in detail later.

  The control unit 32 has a function of controlling the operation of each unit of the medical information management apparatus 10. The control unit 32 includes a display control unit 34.

  The display control unit 34 has a function of controlling the display of the execution record document and other information. For example, the display control unit 34 may cause the UI unit 36 (user interface unit) or the terminal device 12 of the medical information management apparatus 10 to display an implementation record document, an implementation record document registration screen, a registration status screen, and the like. .

  The UI unit 36 is a user interface unit and includes a display unit and an operation unit. The display unit is a display device such as a liquid crystal display. The operation unit is an input device such as a touch panel or a keyboard. Of course, the UI unit 36 may be a user interface that serves as both a display unit and an operation unit (for example, a touch-type display). The medical information management apparatus 10 may not include the UI unit 36.

  Hereinafter, the terminal device 12 will be described in detail with reference to FIG. FIG. 3 shows the configuration of the terminal device 12.

  The communication unit 38 is a communication interface and has a function of transmitting data to other devices and a function of receiving data from other devices. The communication unit 38 may be a communication interface having a wireless communication function or a communication interface having a wired communication function.

  The storage unit 40 is a storage device such as a hard disk or a memory, and stores various programs, various data, address information of external devices (for example, address information of the medical information management device 10), and the like.

  The UI unit 42 is a user interface unit and includes a display unit and an operation unit. The display unit is a display device such as a liquid crystal display. The operation unit is an input device such as a touch panel or a keyboard. Of course, the UI unit 42 may be a user interface (for example, a touch-type display) that serves as both a display unit and an operation unit.

  The control unit 44 has a function of controlling the operation of each unit of the terminal device 12. The control unit 44 functions as a display control unit, for example, and causes the UI unit 42 to display various types of information.

  The terminal device 12 is used, for example, when registering or referring to an implementation record document. For example, when registering an implementation record document, an implementation record document registration screen is displayed on the UI unit 42 of the terminal device 12, and an operator such as a medical worker performs an operation record document registration operation using the terminal device 12. . Of course, the operator may perform the registration operation using the medical information management device 10 without using the terminal device 12. The terminal device 12 may be used when medical information is audited. In this case, the UI unit 42 of the terminal device 12 displays information indicating whether or not each execution record document is registered.

  Note that the terminal device 12 may include a document registration unit 26, a registration status evaluation unit 28, and a document analysis unit 30, and perform data creation, registration processing, analysis, and the like of the implementation record document. Further, the terminal device 12 includes a patient information storage unit 18, a document type definition storage unit 20, an analysis area information storage unit 22, and a document storage unit 24, and stores the data of the implementation record document and stores the document type definition information. You may memorize | store it or memorize | store management information.

  Hereinafter, patient information will be described in detail with reference to FIG. FIG. 4 shows an example of a patient management table as patient information. The data of the patient management table is stored in the patient information storage unit 18.

  In the patient management table, for example, patient ID, patient name, sex, date of birth, hospitalization date, and the like are associated with each other. For example, when a patient undergoes a medical examination, examination, treatment, or the like at a hospital or is admitted to the hospital, the patient information is registered in the patient management table.

  Hereinafter, the document type definition information will be described in detail with reference to FIG. FIG. 5 shows an example of a document type definition table as document type definition information. The data of the document type definition table is created in advance and stored in the document type definition storage unit 20.

  In the document type definition table, for example, a document type ID as identification information of an implementation record document type, information indicating the implementation record document type, and a medical record to be recorded in the implementation record document having the implementation record document type as attributes. Information indicating a medical practice type as an attribute of an action is associated with each other.

  For example, a medical practice type “medical information provision” and an execution record document type “medical information provision form” are associated with each other. A medical practice having the medical practice type “medical information provision” as an attribute is a medical practice to be recorded in an implementation record document having the clinical record type “medical information provision form” as an attribute. In other words, the implementation record document having the implementation record document type “medical information provision form” as an attribute is a document in which the implementation of the medical practice having the medical procedure type “provide medical information” as an attribute is recorded.

  Hereinafter, the analysis region information will be described in detail with reference to FIG. FIG. 6 shows an example of an analysis area definition table as analysis area information. Data of the analysis area definition table is created in advance and stored in the analysis area information storage unit 22.

  In the analysis area definition table, for example, a document type ID, an implementation record document type, and information indicating an analysis area of an implementation record document having the implementation record document type as attributes are associated with each other. The analysis area is defined by, for example, a position (for example, X coordinate, Y coordinate) in the implementation record document, the width and height of the area, the page number to be analyzed, and the like.

  For example, the analysis area of the implementation record document having the implementation record document type “medical information provision form” as an attribute is at a position determined by the X coordinate (300) and the Y coordinate (100) in the second page of the document. The region has a width (500) and a height (200).

  The document analysis unit 30 acquires information indicating the analysis area associated with the execution record document type as an attribute of the analysis record to be analyzed from the analysis area definition table, and stores the information in the analysis area of the analysis record to be analyzed. Analyze the recorded contents.

  Hereinafter, the management information will be described in detail with reference to FIG. FIG. 7 shows an example of a document management table as management information. Data of the document management table is stored in the document storage unit 24.

  In the document management table, for example, document identification information (eg, document ID) for identifying an implementation record document, document type ID, and information (eg, document name) indicating an implementation record document in which medical practice has been recorded. ) And a patient ID for identifying a patient for whom the medical practice has been performed are associated with each other. As information other than these, information indicating the storage location of the data of the implementation record document (for example, address information such as URL) may be associated with the above information.

  For example, when an instruction to register an execution record document is given by the operator, the document registration unit 26 adds management information about the execution record document to the document management table and updates the document management table. As a result, the execution record document to be registered is registered in the medical information management system. The execution record document registered in the document management table is a document in which data or paper as its entity exists, and corresponds to an entity registration document. For example, data as an actual recorded document is stored in the document storage unit 24. An implementation record document that is not registered in the document management table corresponds to an unregistered implementation record document. By referring to the document management table, the execution record document registered in the medical information management system is specified.

  Hereinafter, with reference to FIG. 8, a determination process (first determination process) for the presence / absence of deemed registration will be described. FIG. 8 schematically shows an implementation record document.

  For example, when the implementation record document 46 (test treatment result report) having the implementation record document type D as an attribute is not registered in the document management table as a specific implementation record document, the implementation having the implementation record document type A as an attribute The record document 48 (introduction letter) and the execution record document 50 (medical information provision form) having the execution record document type B as an attribute are analyzed as related execution record documents.

  As a result of the analysis, hospital information (for example, hospital name, doctor name, address, telephone number, etc.) recorded in the analysis area 48a in the implementation record document 48 (introduction letter) and an implementation record document 50 (providing medical information) If the hospital information recorded in the analysis area 50a is in a correspondence relationship, the implementation record document 46 (test treatment result report) having the implementation record document type D as an attribute is registered in the medical information management system. It can be regarded as being done. That is, it is determined that the implementation record document 46 corresponds to the deemed registration document. The case where both hospital information has a correspondence relationship is, for example, a case where part or all of the information included in both hospital information matches each other.

  The referral letter is an implementation record document sent from the referral source hospital 1 to the referral destination hospital 2. Usually, the referral letter contains the hospital information of the referral source hospital 1 as information indicating the sender. It is recorded. In order to extract the hospital information, the analysis area 48a is defined as an area where hospital information as sender information is assumed to be recorded in the introduction letter.

  In addition, a medical information provision form may be sent from the second hospital to the first hospital together with a test treatment result report. In this case, the hospital information of the first hospital as the introduction source is recorded as information indicating the destination in the medical care information provision form. In order to extract the hospital information, the analysis area 50a is set to an area where hospital information as destination information is assumed to be recorded in the medical care information provision form.

  The hospital information as the sender information recorded in the referral letter and the hospital information as the destination information recorded in the medical care information offer form have a corresponding relationship. It is an implementation record document sent to the first hospital as the sender, and the medical care information provision form records the medical results performed at the second hospital in relation to the medical results at the first hospital. Guessed. In other words, if a medical treatment was conducted at the second hospital in response to an introduction from the first hospital, a test treatment result report was created at the second hospital in order to report the results of the medical treatment. Sent to the first hospital, the medical treatment information report in which the hospital information of the first hospital is recorded without creating the test and treatment result report is registered. It is presumed that the treatment result report is also sent from the second hospital to the first hospital.

  In addition, the medical information provided by the second hospital and presumed to be sent to the first hospital includes the medical treatment at the second hospital corresponding to the medical result at the first hospital (for example, the medical result of hypertension). It is presumed that a result (for example, a medical result of hypertension) is recorded. Of course, the medical care information provision form created at the second hospital may record medical results (for example, cold medical results) that do not correspond to the medical results at the first hospital. On the other hand, since the test treatment result report is usually a document in which the medical treatment result in the second hospital corresponding to the medical treatment result in the first hospital is recorded, It can be said that it is a document that includes the recorded contents of a book.

  Based on the above assumptions, if the hospital information recorded in the referral letter and the hospital information recorded in the medical information provision form have a corresponding relationship, the medical information provision form corresponds to the medical result in the first hospital. The result of medical treatment at the second hospital is recorded and presumed to be a document sent from the second hospital to the first hospital. That is, it can be said that the medical information provision form is a document that also serves as a test treatment result report. Therefore, even if there is no data or form as the substance of the test treatment result report and the test treatment result report is not actually registered in the medical information management system, the test treatment result report is stored in the medical information management system. It can be considered registered. This is because a medical information provision form including the recorded contents of the test treatment result report is created and registered.

  In the above example, the referral letter corresponds to an example of the first implementation record document, the medical care information provision document corresponds to an example of the second implementation record document, and the test treatment result report includes the third implementation record document. It corresponds to an example.

  Hereinafter, another determination process (second determination process) will be described with reference to FIG. 9. FIG. 9 schematically shows an implementation record document.

  When the implementation record document 46 (examination treatment result report) having the implementation record document type D as an attribute is not registered in the document management table, the implementation record document 52 (visit report) having the implementation record document type C as an attribute is stored. Is analyzed as a related implementation record document.

  In the visit report, the doctor's findings corresponding to the test treatment result report may be recorded and sent from the referral second hospital to the referral source first hospital. In other words, the visit report may also serve as a test treatment result report.

  As a result of the analysis of the visit report, when the findings of the doctor are recorded in the analysis area 52a in the execution record document 52 (visit report), the execution record document 46 (examination treatment result) having the execution record document type D as an attribute Report) is registered. That is, it is determined that the implementation record document 46 corresponds to the deemed registration document. In order to extract the doctor's findings, the analysis area 52a is defined as an area where the doctor's findings are assumed to be recorded in the visit report.

  In the above example, the examination treatment report corresponds to an example of the third implementation record document, and the visit report corresponds to an example of the fourth implementation record document.

  The implementation record document registration process will be described in detail below with reference to the flowchart shown in FIG.

  For example, it is assumed that an operator performs an operation for registering an implementation record document using the terminal device 12. In this case, when the worker accesses the medical information management apparatus 10 using the terminal device 12 and requests registration of the execution record document, data on the registration screen is transmitted from the medical information management apparatus 10 to the terminal device 12, and the registration screen is displayed. Is displayed on the UI unit 42 of the terminal device 12. Of course, the operator may perform an operation for registering an execution record document using the medical information management apparatus 10. In this case, a registration screen is displayed on the UI unit 36 of the medical information management apparatus 10. In the following, it is assumed that a registration operation is performed using the terminal device 12.

  For example, when the implementation record document to be registered is composed of paper, when the implementation record document is read by the scanner, the document registration unit 26, based on the result of the reading, stores data (actual data of the implementation record document). For example, image data or text data) is created. For example, when an image or character string of an implementation record document created by the reading is displayed on the registration screen and the operator instructs registration, the document registration unit 26 stores the data of the implementation record document in the document storage unit 24. (S01). Note that, when the implementation record document to be registered is composed of digitized data, the document registration unit 26 stores the data itself in the document storage unit 24.

  Further, the document registration unit 26 registers the management information of the implementation record document to be registered in the document management table shown in FIG. 7 (S02). As a result, an implementation record document to be registered (an implementation record document in which data or paper as an entity exists) is registered (entity registration) in the medical information management system as an entity registration document.

  In the implementation record document, patient identification information, information indicating an implementation record document type as an attribute of the implementation record document, and the like are described as code information. The code information is also read by reading the implementation record document by the scanner, and the document registration unit 26 analyzes the code information to acquire information indicating the patient identification information and the implementation record document type, and manages the information. Register it in the document management table as information. When an electronic implementation record document is used, the data of the implementation record document is associated with patient identification information, information indicating the implementation record document type, and the like as supplementary information. Information included in the information is registered in the document management table as management information. Of course, the operator may input patient identification information and information indicating an execution record document type, or the document registration unit 26 may acquire such information from another device.

  Hereinafter, the process performed by the registration status evaluation unit 28 will be described in detail with reference to the flowchart shown in FIG.

  When the registration status evaluation unit 28 receives the request for the evaluation process (S10), the registration status evaluation unit 28 acquires management information of the implementation record document for each patient from the document storage unit 24 (S11). For example, the registration status evaluation unit 28 acquires management information of an execution record document for each patient registered in the document management table shown in FIG.

  Next, the registration status evaluation unit 28 refers to the management information of the implementation record document for each patient, and identifies patients who have not been registered with the implementation record document (test treatment result report) having the implementation record document type D as an attribute. Detect (S12).

  When there is a patient to whom an execution record document (test treatment result report) having the execution record document type D as an attribute is not registered (S12, Yes), the registration status evaluation unit 28 is a patient for identifying the patient The information is added to the processing target list (S13), and the processing target list is output to the document analysis unit 30 (S14). Upon receiving information indicating the analysis result from the document analysis unit 30, the registration status evaluation unit 28 outputs evaluation result information (information including management information and information indicating the analysis result) to the display control unit 34 (S15).

  The management information is information indicating an implementation record document registered in the medical information management system, and the information indicating the analysis result is information indicating the implementation record document registered as deemed later. Accordingly, the evaluation result information is information including information indicating the registered implementation record document and information indicating the deemed implementation record document, and the registration status (registered, unregistered) of each implementation record document. Or deemed registration).

  When there is no patient in which the execution record document (test treatment result report) having the execution record document type D as an attribute does not exist (S13, No), the evaluation result information (information including management information) is displayed on the display control unit 34. (S15).

  Hereinafter, the process performed by the document analysis unit 30 will be described in detail with reference to the flowcharts shown in FIGS.

  Upon receiving the processing target list from the registration status evaluation unit 28, the document analysis unit 30 sequentially processes the patient information included in the processing target list (S20).

  First, the document analysis unit 30 includes, for the patient to be processed, an implementation record document (introduction letter) having the implementation record document type A as an attribute and an implementation record document (medical information provision form) having the implementation record document type B as an attribute. It is determined whether or not both are registered in the medical information management system (S21). Specifically, the document analysis unit 30 performs an implementation record document (introduction letter) having the implementation record document type A as an attribute in the patient information to be processed (for example, patient ID) in the document management table shown in FIG. ) And an execution record document (medical information provision form) having the execution record document type B as an attribute are determined to be associated with each other.

  When both the referral letter and the medical information provision form are registered in the medical information management system for the patient to be processed (S21, Yes), that is, in the document management table, the referral letter and the medical care are included in the patient information to be processed. If both of the information provision documents are associated, the process proceeds to step S22.

  On the other hand, regarding the patient to be processed, when one or both of the referral letter and the medical information provision form are not registered in the medical information management system (S21, No), that is, in the document management table, If any one or both of the referral letter and the medical information provision form is not associated with the patient information, the process proceeds to step S27.

  In step S22, the document analysis unit 30 sets, from the analysis area information storage unit 22, the information indicating the analysis area of the implementation record document (introduction letter) having the implementation record document type A as an attribute, and the implementation record document type B as an attribute. And information indicating the analysis area of the implementation record document (medical information provision form). Specifically, the document analysis unit 30 obtains information indicating the analysis area (analysis area for the introduction letter) associated with the execution record document type A from the analysis area definition table shown in FIG. Information indicating an analysis region (analysis region for medical information provision document) associated with the document type B is acquired. In addition, the document analysis unit 30 receives, from the document storage unit 24, data of an implementation record document (introduction letter data) having the implementation record document type A as an attribute, and data of an implementation record document having the implementation record document type B as an attribute. (Data of medical information provision form) is acquired.

  Next, the document analysis unit 30 extracts the character string from the analysis area by applying image analysis to the analysis area for the referral letter in the referral letter data, and the medical information in the medical information provision form data By applying image analysis to the analysis area for the provided document, a character string is extracted from the analysis area (S23). In the example shown in FIG. 8, a character string is extracted from the analysis area 48a of the implementation record document 48, which is an introduction letter, and a character string is extracted from the analysis area 50a of the implementation record document 50, which is a medical information provision document.

  Next, the document analysis unit 30 applies natural language analysis to the character string extracted from the data of the referral letter, and applies natural language analysis to the character string extracted from the data of the medical information provision document. (S24). In the example shown in FIG. 8, natural language analysis is applied to the analysis regions 48a and 50a.

  Next, the document analysis unit 30 compares the result of the natural language analysis with respect to the data of the referral letter and the result of the natural language analysis with respect to the data of the medical care information provision book (S25). That is, the result of the natural language analysis for the analysis area 48a of the introduction letter is compared with the result of the natural language analysis for the analysis area 50a of the medical information provision document.

  When the hospital information obtained as a result of the natural language analysis for the data of the referral letter and the hospital information obtained as a result of the natural language analysis for the data of the medical care information provision document have a correspondence relationship (S25, Yes), The document analysis unit 30 determines that an implementation record document (examination treatment result report) having the implementation record document type D as an attribute is registered in the medical information management system for the patient to be processed (S26). That is, if the hospital information recorded in the analysis area 48a of the referral letter and the hospital information recorded in the analysis area 50a of the medical care information provision form have a correspondence relationship, the test treatment result report for the patient to be processed Is considered registered. The document analysis unit 30 holds information indicating the determination result (information indicating that the examination treatment result report is regarded and registered for the patient to be processed).

  For example, in both hospital information, when all of the hospital name, doctor name, address, and telephone number match each other, it may be determined that both hospital information has a correspondence relationship, and at least one of the information is included. When the information of the departments match each other, it may be determined that both hospital information has a correspondence relationship. The fact that both hospital information has a correspondence relationship means that the sender hospital (first hospital) recorded in the referral letter and the hospital (first hospital) as the destination recorded in the medical information provision form, (For example, at least some of the hospital name, doctor name, address, and telephone number match each other).

  On the other hand, the hospital information obtained as a result of the natural language analysis for the data of the referral letter and the hospital information obtained as a result of the natural language analysis for the data of the medical information provision form have no correspondence ( (S25, No), the process proceeds to step S27.

  Hereinafter, with reference to FIG. 13, the processing after step S <b> 27 will be described. As described above, when one or both of the referral letter and the medical information provision form are not registered in the medical information management system for the patient to be processed, the processes after step S27 are executed. Further, when the hospital information recorded in the analysis area of the referral letter and the hospital information recorded in the analysis area of the medical care information provision form do not have a correspondence relationship, the processing from step S27 is executed.

  First, the document analysis unit 30 determines whether or not an implementation record document (visit report) having an implementation record document type C as an attribute is registered in the medical information management system for the patient to be processed (S27). Specifically, the document analysis unit 30 performs an implementation record document (visit report) having an implementation record document type C as an attribute in the patient information to be processed (for example, patient ID) in the document management table shown in FIG. Is determined to be associated with each other.

  When the execution record document (visit report) having the execution record document type C as an attribute is not registered in the medical information management system for the patient to be processed (S27, No), that is, in the document management table, If the visit report is not associated with the patient information, the process proceeds to step S33. In this case, the document analysis unit 30 executes the processing from step S21 described above on the next patient information in the processing target list.

  When the execution record document (visit report) having the execution record document type C as an attribute is registered in the medical information management system for the patient to be processed (S27, Yes), that is, in the document management table, If the visit report is associated with the patient information, the process proceeds to step S28.

  In step S <b> 28, the document analysis unit 30 acquires information indicating the analysis region of the execution record document (visit report) as an attribute of the execution record document type C from the analysis region information storage unit 22. Specifically, the document analysis unit 30 acquires information indicating the analysis region (the analysis region for the visit report) associated with the implementation record document type C from the analysis region definition table shown in FIG. . In addition, the document analysis unit 30 acquires data of an implementation record document (visit report data) having the implementation record document type C as an attribute from the document storage unit 24.

  Next, the document analysis unit 30 extracts a character string from the analysis area by applying image analysis to the analysis area for the visit report in the data of the visit report (S29). In the example shown in FIG. 9, a character string is extracted from the analysis area 52a of the implementation record document 52 which is a visit report.

  Next, the document analysis unit 30 applies natural language analysis to the character string extracted from the data of the visit report (S30). In the example shown in FIG. 9, natural language analysis is applied to the analysis region 52a.

  Next, the document analysis unit 30 determines whether information indicating doctor's findings is included in the analysis result (S31). That is, it is determined whether or not the doctor's findings are recorded in the analysis area 52a of the visit report.

  When the analysis result includes information indicating a doctor's findings (S31, Yes), the document analysis unit 30 performs an execution record document (test / treatment result report) having the execution record document type D as an attribute for the patient to be processed. Is determined to be registered in the medical information management system (S32). That is, when a doctor's findings are recorded in the analysis area 52a of the visit report, it is considered that the test treatment result report is registered for the patient to be processed. The document analysis unit 30 holds information indicating the determination result (information indicating that the examination treatment result report is regarded and registered for the patient to be processed).

  On the other hand, when the analysis result does not include information indicating the doctor's findings (S31, No), the process proceeds to step S33. In this case, the document analysis unit 30 executes the processing from step S21 described above on the next patient information in the processing target list.

  When the above processing is performed up to the last patient information included in the processing target list (S34), the analysis processing by the document analysis unit 30 ends.

  When the analysis process ends, the document analysis unit 30 outputs information indicating the analysis result to the registration status evaluation unit 28. The information indicating the analysis result includes information indicating the above determination result (information indicating that the examination treatment result report is regarded and registered for the patient to be processed).

  In the example shown in FIGS. 12 and 13, the first determination process (determination process using the introduction letter and the medical information provision document) is performed first, and then the second determination process (determination using the visit report) is performed. However, the second determination process may be performed first, and then the first determination process may be performed. Further, only the first determination process may be performed without performing the second determination process, or only the second determination process may be performed without performing the first determination process.

  Hereinafter, the processing by the display control unit 34 will be described in detail with reference to the flowchart shown in FIG.

  For example, the worker uses the terminal device 12 to access and log in to the medical information management apparatus 10 and requests a document registration status display process (S40). For login, for example, user information such as a user ID and a password is used.

  Next, when the display control unit 34 receives the request for the display process, the display control unit 34 requests the registration status evaluation unit 28 to evaluate the registration status of the implementation record document (S41).

  Upon receiving an instruction from the display control unit 34, the registration status evaluation unit 28 performs processing according to the flowchart shown in FIG. 11, and the document analysis unit 30 performs processing according to the flowcharts shown in FIGS. Do. The display control unit 34 acquires evaluation result information from the registration status evaluation unit 28 (S42). The evaluation result information includes management information, and also includes information indicating the analysis result when the document analysis unit 30 performs analysis.

  The display control unit 34 performs processing for displaying information related to the registration status of each implementation record document. At this time, the display control unit 34 performs display processing according to the registration status of each execution record document indicated by the evaluation result information (S43). Information regarding the registration status is transmitted from the medical information management device 10 to the terminal device 12 and displayed on the UI unit 42 of the terminal device 12, for example. Of course, the information regarding the registration status may be displayed on the UI unit 36 of the medical information management apparatus 10.

  The display control unit 34 displays a display mode of information related to a registration status of an actual registration document (substance registration document), a display mode of information related to a registration status of an unregistered execution record document, and an execution record that is regarded as registered. A display process of information related to the registration status is performed by changing the display mode of the information related to the registration status of the document (deemed registered document). For example, the display control unit 34 may change the shape, pattern, color, brightness, and the like of an image (for example, an icon) representing the registration status in accordance with the registration status.

  Hereinafter, the execution record document display processing will be described in detail with reference to the flowchart shown in FIG.

  As described above, in a state where information related to the registration status of each execution record document is displayed on the UI unit 42 of the terminal device 12, the operator uses the terminal device 12 to indicate information indicating the execution record document (for example, the execution record). When an image such as an icon associated with a recorded document is selected (S50), the display control unit 34 performs display processing according to the registration status of the implementation recorded document selected by the operator. In the following description, it is assumed that the implementation record document is displayed on the terminal device 12, but the implementation record document may be displayed on the medical information management apparatus 10.

  When information indicating the actual record document registered as an entity is selected by the operator (S51), the display control unit 34 acquires the data of the selected actual record document from the document storage unit 24, and the actual record is recorded. The contents of the document are displayed on the terminal device 12 (S52).

  When information indicating an unrecorded implementation record document is selected by the operator (S53), the display control unit 34 displays information indicating that the selected implementation record document is not registered on the terminal device 12. (S54).

  When information indicating the execution record document that has been regarded as being registered is selected by the operator (S55), the display control unit 34 selects another execution record document (related execution record document) related to the selected execution record document. Data is acquired from the document storage unit 24, and the contents of the related execution record document are displayed on the terminal device 12 (S56).

  For example, an implementation record document type D is obtained by analyzing an implementation record document (introduction letter) having the implementation record document type A as an attribute and an implementation record document (medical information provision form) having the implementation record document type B as an attribute. When it is considered that the implementation record document (examination treatment result report) having the attribute is registered, the display control unit 34 causes the terminal device 12 to display the introduction letter and the medical information provision form as the related implementation record document. In addition, when it is determined that an implementation record document having the implementation record document type D as an attribute is registered by analyzing an implementation record document (visit report) having the implementation record document type C as an attribute, display control is performed. The unit 34 causes the terminal device 12 to display the visit report as a related implementation record document.

  Hereinafter, a screen indicating the registration status of the implementation record document (hereinafter referred to as “registration status screen”) will be described. FIG. 16 shows an example of a registration status screen.

  As described above, when the worker uses the terminal device 12 to request display of the registration status of the document, the registration status screen data is transmitted from the medical information management device 10 to the terminal device 12 and the UI of the terminal device 12 is displayed. Displayed on the unit 42. Of course, the registration status screen may be displayed on the UI unit 36 of the medical information management apparatus 10. The registration status screen data is created by, for example, the display control unit 34 of the medical information management apparatus 10. The registration status screen is displayed, for example, when a medical audit is performed, and the audit is performed based on information displayed on the registration status screen. During the audit, the medical information management device 10 functions as a medical audit device.

  On the registration status screen 54, an image (for example, an icon) representing the registration status of each execution record document is displayed for each patient. The registered image 56 is an image indicating that the implementation record document corresponding to the registered image 56 is an entity registered document (entity registered document). The unregistered image 58 is an image indicating that the implementation record document corresponding to the unregistered image 58 is not registered in the medical information management system. The registered image 56 and the unregistered image 58 have different display modes. For example, the registered image 56 and the unregistered image 58 have different image shapes, colors, brightness, and the like.

  For example, on the registration status screen 54, for each patient, an image indicating the registration status of an implementation record document (introduction letter) having an implementation record document type A “introduction letter from another hospital” as an attribute, “medical information provision form” An image representing the registration status of an implementation record document (medical information provision form) having an implementation record document type B as an attribute, an implementation record document (visit report) having an implementation record document type C as an attribute An image showing the registration status of the implementation record document (examination treatment result report) having the implementation record document type D “examination treatment result report” as an attribute is displayed.

  Explaining with a specific example, for a patient having a patient ID of “FXPAT002”, the referral letter and the medical information provision form are registered in substance, and the visit report and the test treatment result report are unregistered. .

  In the example shown in FIG. 16, the implementation record document (deemed registration document) that is regarded as being registered is also displayed as an unregistered implementation record document. That is, the unregistered image 58 is displayed as an image representing the registration status of the deemed registered document.

  The registration status screen 54 has a document display area 60. In the document display area 60, a list of other implementation record documents (related implementation record documents) related to the deemed registered document is displayed. For example, for a patient having a patient ID of “FXPAT002”, an implementation record document (introduction letter) having the implementation record document type A as an attribute and an implementation record document (medical information provision form) having the implementation record document type B as an attribute. When it is considered by analysis that the implementation record document (test / treatment result report) having the implementation record document type D as an attribute is registered, the display control unit 34 relates the introduction letter and the medical information provision form. It is displayed in the document display area 60 as an execution record document. Similarly, an implementation record document (test treatment result report) having the implementation record document type D as an attribute is registered by analyzing an implementation record document (visit report) having the implementation record document type C as an attribute. When it is considered that the display control unit 34 displays the visit report as a related execution record document in the document display area 60. As described above, in the example shown in FIG. 16, the unregistered image 58 is displayed as an image representing the registration status of the deemed registered document. In the document display area 60, the related implementation record document related to the deemed registered document is displayed. Is displayed. For example, when the operator specifies a patient ID on the registration status screen 54, the display control unit 34 displays a related execution record document in the document display area 60 for the patient having the patient ID.

  Further, the display control unit 34 may display the analysis area in the related execution record document displayed in the document display area 60 separately from other areas. The display control unit 34 may highlight the analysis region as indicated by reference numerals 62, 64, 66, for example. This makes it easy for the operator to specify the analysis area.

  FIG. 17 shows another registration status screen 68. Similar to the registration status screen 54 shown in FIG. 16, the registration status screen 68 displays an image (for example, an icon) representing the registration status of each execution record document for each patient. The registered image 70 is an image representing that the implementation record document corresponding to the registration image 70 is an implementation record document (entity registration document) in which entity registration has been performed. The unregistered image 72 is an image indicating that the implementation record document corresponding to the unregistered image 72 is not registered in the medical information management system. The deemed registration image 74 is an image indicating that the implementation record document corresponding to the deemed registration image 74 is an implementation record document (deemed registration document) registered as deemed. The registered image 70 and the unregistered image 72 are different from each other in the display mode (for example, the shape, color, brightness, and the like of the image).

  For example, for a patient having a patient ID of “FXPAT002”, the referral letter and the medical care information provision form are actually registered, the visit report is unregistered, and the examination treatment result report is regarded as registered. .

  When the registered image 70 is designated by the operator on the registration status screen 68, the display control unit 34 stores the data as the entity of the implementation record document (entity registered document) corresponding to the designated registered image 70 in the document storage. The image of the implementation record document obtained from the unit 24 is displayed on the UI unit 42 of the terminal device 12.

  For example, regarding the patient having the patient ID “FXPAT003”, when the registered image 70 corresponding to the implementation record document type C “visit report” is designated by the worker, the display control unit 34 is designated by the worker. The actual data of the execution record document (visit report) corresponding to the registered image 70 is acquired from the document storage unit 24, and the image of the execution record document (visit report) is stored in the UI unit 42 of the terminal device 12. Display. FIG. 18 shows an example of an image as an entity of a visit report designated by an operator. This image is displayed on the UI unit 42 of the terminal device 12.

  When the unregistered image 72 is designated by the operator on the registration status screen 68, the display control unit 34 indicates that the implementation record document corresponding to the designated unregistered image 72 is medical, as shown in FIG. Information (for example, a message) indicating that it is not registered in the information management system is displayed on the UI unit 42 of the terminal device 12.

  When the deemed registration image 74 is designated by the operator on the registration status screen 68, the display control unit 34 relates to the implementation record document (deemed registration document) corresponding to the designated deemed registration image 74. Data as the entity of the execution record document is acquired from the document storage unit 24, and an image of the related execution record document is displayed on the UI unit 42 of the terminal device 12.

  For example, in the registration status screen 68 shown in FIG. 17, regarding the patient having the patient ID “FXPAT002”, an assumed registered image 74 corresponding to the execution record document type D “test treatment result report” is displayed by the operator. When designated, the display control unit 34 acquires, from the document storage unit 24, data as an entity of the related execution record document related to the execution record document (examination treatment result report) having the execution record document type D as an attribute. Then, the image of the related execution record document is displayed on the UI unit 42 of the terminal device 12. For a patient having a patient ID of “FXPAT002”, an implementation record document (introduction letter) having an implementation record document type A of “introduction letter from another hospital” as an attribute and an implementation record document type of “medical information provision form” An implementation record document (medical information provision form) having B as an attribute exists as an entity, and an introduction letter and a medical information provision form are registered in the medical information management system. When it is considered that the test and treatment result report is registered by analyzing the referral letter and the medical care information provision form, the referral letter and the medical information provision form are related to the test and treatment result report as the deemed registration document. Corresponds to related implementation record documents In this case, the display control unit 34 acquires data as an introduction letter entity and data as a medical information provision form entity from the document storage unit 24, and obtains an introduction letter image and a medical information provision form image as the terminal device 12. Are displayed on the UI unit 42 of the screen.

  FIG. 20 shows an introduction letter image 76 and a medical information provision form image 78 as related implementation record documents related to the test treatment result report. The images 76 and 78 are displayed on the UI unit 42 of the terminal device 12. The referral letter is a document created at the first hospital of the patient referral source, and the medical care information provision document is a document created at the second hospital of the patient referral destination. The referral letter also records the contents of the medical information provision form sent from the first hospital to the second hospital when introducing the patient.

  The display control unit 34 displays the analysis area 76a in the referral letter represented by the image 76 separately from the other areas, and displays the analysis area 78a in the medical care information provision form represented by the image 78 as the other area. You may distinguish and display. For example, the display control unit 34 may highlight and display the analysis regions 76a and 78a, or may display the analysis regions 76a and 78a surrounded by a frame or the like. This makes it easy for the operator to specify the analysis area. Since the referral letter represented by the image 76 is a document sent from the first hospital that is the referral source of the patient to the second hospital that is the referral destination, the analysis area 76a in the referral letter that is represented by the image 76 contains the referral letter. The original hospital information of the first hospital is recorded as sender information of the introduction letter. Since the medical information provision form represented by the image 78 is a document sent from the second hospital to the first hospital, the analysis area 78a in the medical information provision form represented by the image 78 contains the first information of the introduction source. The hospital information of the hospital is recorded as the destination information. Since the sender and the destination have a correspondence (for example, match), it is considered that the test treatment result report is registered.

  As another example, in the registration status screen 68 shown in FIG. 17, regarding the patient having the patient ID “FXPAT003”, the deemed registration image 74 corresponding to the execution record document type D “test treatment result report” is displayed. When designated by the operator, the display control unit 34 stores data as an entity of the related execution record document related to the execution record document (examination treatment result report) having the execution record document type D as an attribute. 24, and the image of the related execution record document is displayed on the UI unit 42 of the terminal device 12. For a patient having a patient ID of “FXPAT003”, there is an execution record document (visit report) having an execution record document type C “visit report” as an attribute, and the visit report is medical information management. Registered in the system. If it is considered that the test and treatment result report is registered by analyzing the visit report, the visit report corresponds to the related implementation record document related to the test and treatment result report as the deemed registration document. In this case, the display control unit 34 acquires data as the substance of the visit report from the document storage unit 24 and causes the UI unit 42 of the terminal device 12 to display an image of the visit report.

  FIG. 21 shows an image 80 of the visit report as a related implementation record document related to the test treatment result report. The image 80 is displayed on the UI unit 42 of the terminal device 12. The visit report is a document created at the second hospital where the patient is referred.

  The display control unit 34 may display the analysis area 80a in the visit report represented by the image 80 separately from other areas. For example, the display control unit 34 may display the analysis region 80a with emphasis or may be displayed surrounded by a frame or the like. Since the findings of the doctor are recorded in the analysis area 80a, it is considered that the test treatment result report is registered.

  As described above, according to the present embodiment, when the hospital information recorded in the specific area of the referral letter and the hospital information recorded in the specific area of the medical information provision form have a correspondence relationship, the medical information is provided. Therefore, it can be considered that the test treatment result report is registered in the medical information management system. As a result, when the substance of the test treatment result report does not exist, it is determined that the medical practice to be recorded in the test treatment result report is recorded in the implementation record document other than the test treatment result report. Is done. In addition, if a doctor's findings are recorded in a specific area of the visit report, it is presumed that the visit report also serves as a test treatment result report, so the test treatment result report is registered in the medical information management system. It can be regarded as being done.

  In addition, the registration status of each implementation record document is presented. Compared to the case where the registration status is not presented, for example, at the time of auditing, it becomes easier for the auditor to determine the registration status of the implementation record document. Also, by displaying the registered images as distinguished from the registered images, it is easier to determine whether or not the implementation record document is a registered document as compared to displaying them without distinguishing them.

  In the embodiment described above, the data of the execution record document corresponds to, for example, one document file, but this is only an example, and the data of the execution record document may be data including a plurality of document files, It may be information provided by a medical chart system or the like.

  Each of the medical information management device 10 and the terminal device 12 is realized by cooperation of hardware and software, for example. Specifically, each of the medical information management device 10 and the terminal device 12 includes one or more processors such as a CPU (not shown). The function of each part of the medical information management device 10 and the terminal device 12 is realized by the one or more processors reading and executing a program stored in a storage device (not shown). The program is stored in the storage device via a recording medium such as a CD or DVD, or via a communication path such as a network. As another example, the units of the medical information management apparatus 10 and the terminal apparatus 12 may be realized by hardware resources such as a processor, an electronic circuit, and an ASIC (Application Specific Integrated Circuit). In the realization, a device such as a memory may be used. As yet another example, each unit of the medical information management device 10 and the terminal device 12 may be realized by a DSP (Digital Signal Processor), an FPGA (Field Programmable Gate Array), or the like.

  DESCRIPTION OF SYMBOLS 10 Medical information management apparatus, 12 Terminal device, 18 Patient information storage part, 20 Document type definition storage part, 22 Analysis area information recording part, 24 Document storage part, 26 Document registration part, 28 Registration status evaluation part, 30 Document analysis part 32 control unit, 34 display control unit.

Claims (13)

Registering the first implementation record document having the first implementation record document type pre-associated with the first implementation type document as an attribute of the first implementation and recording the implementation of the first implementation procedure; The second medical record type associated in advance with the second medical practice type as an attribute of the second medical practice is used as an attribute, the implementation of the second medical practice is recorded, and the presence of the first medical record document Registration means for registering a second execution record document created in response to the request;
In the case where the third implementation record document having the third implementation record document type previously associated with the third medical practice type as the attribute of the third medical practice is not registered by the registration means, the first implementation record When the hospital information recorded in the first specific area of the document and the hospital information recorded in the second specific area of the second implementation record document have a correspondence relationship, the third implementation record document is registered as the registration information. Processing means for processing as a document registered by the means;
Have
It is assumed that the third implementation record document is created according to the presence of the first implementation record document, and information related to the recording contents of the second implementation record document in which the hospital information has the correspondence relationship is assumed. A document
Information processing device. The processing means is a control means for displaying an execution record document on a display means,
The control means makes the display mode of the first execution record document and the second execution record document different from the display mode of the third execution record document processed as a registered document.
The information processing apparatus according to claim 1. The control means causes the display means to display the first execution record document and the second execution record document when the third execution record document processed as the document registered by the processing means is selected. , The first specific area and the second specific area are displayed on the display means separately from other areas,
The information processing apparatus according to claim 2. The first implementation record document is a document created at the first hospital and sent from the first hospital to the second hospital;
The second implementation record document is a document that records the implementation of the second medical practice performed at the second hospital according to the first implementation record document and is sent to the first hospital,
The hospital information having the correspondence relationship is information indicating the first hospital.
The information processing apparatus according to claim 1, wherein the information processing apparatus is an information processing apparatus. The first implementation record document is a document in which first medical information regarding the medical treatment of the patient obtained by treating the patient at the first hospital is recorded,
The second implementation record document is a document in which second medical information regarding medical treatment of the patient obtained by treating the patient at the second hospital is recorded,
The third implementation record document is a document in which information related to at least the first medical information in the second medical information is recorded.
The information processing apparatus according to claim 4. Registration for registering the fourth implementation record document having the fourth implementation record document type previously associated with the fourth implementation category as an attribute of the fourth implementation procedure as an attribute and recording the implementation of the fourth implementation procedure Means,
Third implementation record document that has a third implementation record document type that is associated in advance with a third medical practice type as an attribute of the third medical practice as an attribute, and is assumed to record medical treatment information related to a patient's medical treatment Is not registered by the registration means, and when information indicating a doctor's findings regarding the patient is recorded in a specific area of the fourth implementation record document, the third implementation record document is stored by the registration means. Processing means for processing as a registered document;
An information processing apparatus. The processing means is a control means for displaying an execution record document on a display means,
The control means makes the display mode of the fourth embodiment recorded document different from the display mode of the third embodiment recorded document processed as a registered document.
The information processing apparatus according to claim 6. When the third execution record document is selected, the control means displays the fourth execution record document on the display means, and displays the specific area on the display means separately from other areas.
The information processing apparatus according to claim 7. The fourth implementation record document is a document for reporting to the first hospital that the patient introduced from the first hospital to the second hospital has visited the second hospital,
The third implementation record document is a document in which the medical information regarding the medical care of the patient obtained by treating the patient at the second hospital is recorded.
The information processing apparatus according to claim 6, wherein the information processing apparatus is an information processing apparatus. Registering the first implementation record document having the first implementation record document type pre-associated with the first implementation type document as an attribute of the first implementation and recording the implementation of the first implementation procedure; The second medical record type associated in advance with the second medical practice type as an attribute of the second medical practice is used as an attribute, the implementation of the second medical practice is recorded, and the presence of the first medical record document Registration means for registering a second execution record document created in response to the request;
In the case where the third implementation record document having the third implementation record document type previously associated with the third medical practice type as the attribute of the third medical practice is not recorded by the registration means, the first implementation record When the hospital information recorded in the first specific area of the document and the hospital information recorded in the second specific area of the second implementation record document have a correspondence relationship, the third implementation record document is registered as the registration information. Processing means for processing as a document registered by the means;
When medical information is audited, display control means for displaying information on the presence or absence of registration of the execution record document on the display means as information used for the audit;
Have
It is assumed that the third implementation record document is created according to the presence of the first implementation record document, and information related to the recording contents of the second implementation record document in which the hospital information has the correspondence relationship is assumed. A document
Medical audit equipment. Registration for registering the fourth implementation record document having the fourth implementation record document type previously associated with the fourth implementation category as an attribute of the fourth implementation procedure as an attribute and recording the implementation of the fourth implementation procedure Means,
Third implementation record document that has a third implementation record document type that is associated in advance with a third medical practice type as an attribute of the third medical practice as an attribute, and is assumed to record medical treatment information related to a patient's medical treatment Is not registered by the registration means, and when information indicating a doctor's findings regarding the patient is recorded in a specific area of the fourth implementation record document, the third implementation record document is stored by the registration means. Processing means for processing as a registered document;
When medical information is audited, display control means for displaying information on the presence or absence of registration of the execution record document on the display means as information used for the audit;
A medical auditing device. Computer
Registering the first implementation record document having the first implementation record document type pre-associated with the first implementation type document as an attribute of the first implementation and recording the implementation of the first implementation procedure; The second medical record type associated in advance with the second medical practice type as an attribute of the second medical practice is used as an attribute, the implementation of the second medical practice is recorded, and the presence of the first medical record document A registration means for registering a second execution record document created according to
In the case where the third implementation record document having the third implementation record document type previously associated with the third medical practice type as the attribute of the third medical practice is not registered by the registration means, the first implementation record When the hospital information recorded in the first specific area of the document and the hospital information recorded in the second specific area of the second implementation record document have a correspondence relationship, the third implementation record document is registered as the registration information. Processing means for processing as a document registered by the means;
Function as
It is assumed that the third implementation record document is created according to the presence of the first implementation record document, and information related to the recording contents of the second implementation record document in which the hospital information has the correspondence relationship is assumed. A document
program. Computer
Registration for registering the fourth implementation record document having the fourth implementation record document type previously associated with the fourth implementation category as an attribute of the fourth implementation procedure as an attribute and recording the implementation of the fourth implementation procedure means,
Third implementation record document that has a third implementation record document type that is associated in advance with a third medical practice type as an attribute of the third medical practice as an attribute, and is assumed to record medical treatment information related to a patient's medical treatment Is not registered by the registration means, and when information indicating a doctor's findings regarding the patient is recorded in a specific area of the fourth implementation record document, the third implementation record document is stored by the registration means. Processing means for processing as a registered document;
Program to function as.

Images