JP2000293593A - Electronic medical chart system - Google Patents

Abstract

PROBLEM TO BE SOLVED: To improve the medical treatment efficiency by displaying the diagnostic information and the examination result information aligned vertically on a display means and also displaying the examination request information and the prescription information at the right of those said diagnostic and examination result information. SOLUTION: An electronic medical chart is displayed on the screen of a display device placed at a clinician terminal, and a diagnosis 31, the examination result 33 of an examination request 32 and the examination result 35 of an examination request 34 are displayed at the left side on the screen with the requests 32 and 34 and the treatment/prescription 36 displayed at the right side on the screen respectively. Thereby the diagnostic information can be easily discriminated from the patient medical treatment information. The top- under direction is defined as a time series and the diagnosis 31, requests 32 and 34, treatment/prescription 36, result 33 of the request 32 and result 35 of the request 34 are successively displayed from the upper side. As a result, the correspondence is easily known between said both diagnostic and medical treatment information.

Description

DETAILED DESCRIPTION OF THE INVENTION

[0001]

BACKGROUND OF THE INVENTION 1. Field of the Invention The present invention relates to an electronic medical record system for a doctor in a hospital to record medical treatment.

[0002]

2. Description of the Related Art In hospitals, doctors provide diagnosis,
Perform inspection requests, treatments and prescriptions. These contents are described on a medical record card called a medical chart.

[0003] Diagnosis is the act of determining the name of a disease based on various information of the patient. An examination request is to request a medical person in charge of an examination to obtain detailed information on a patient. The treatment / prescription is a medical practice performed on a patient, and includes, for example, injection and medication.

[0004] A doctor generally performs medical treatment on a patient as follows.

[0005] The doctor requests various tests (test requests) in order to make a diagnosis according to the symptoms of the patient. After that, a diagnosis is made based on the test results, and treatment and prescription are determined. When diagnosing and deciding treatment / prescription, reference is made to the patient's past diagnosis and test results and treatment / prescription.

[0006]

Conventionally, in hospitals, medical records, test results, and test reports have been operated on paper media. Therefore, the doctor has to collect the records made on the past paper medium and link the past histories by his own judgment to refer to them.

In some cases, medical records, test reports, and the like are digitized independently of each other. In this case, however, it is still necessary for the doctor to link past histories by his own judgment and refer to them. .

[0008] As described above, when referring to the relevant information relating to the patient who performs the medical treatment, the physician, the medical chart, the test result,
Inspection reports, whether printed or electronic,
It was necessary to connect and refer to test records, test results, and past diagnostic records by themselves, which hindered the efficiency of medical practice.

[0009] The present invention has been made to solve the above-mentioned problem, and has as its object to provide an electronic medical record system capable of improving the efficiency of medical treatment.

[0010]

In order to solve the above-mentioned problems, an electronic medical record system according to the present invention has at least one electronic medical record storage means in which medical record information of each patient is stored, and test result information of each patient. At least one test data storage means, and display means capable of displaying data stored in the electronic medical record storage means and data stored in the test data storage means, wherein the display means comprises:
At least diagnostic information, test request information, test result information, prescription information can be displayed on the display surface, and the diagnostic information and the test result information can be displayed side by side in the vertical direction, and
The test request information and the prescription information are displayed on the right side of the display of the diagnostic information and the test result information.

[0011]

FIG. 1 is a block diagram showing an embodiment of an electronic medical record system according to the present invention.

In a hospital, a plurality of server computers and a plurality of terminal computers are installed via a network line. In FIG. 1, an electronic medical record server 1, an inspection server 2, 3
Is installed. Also, as a terminal computer,
A clinician terminal 5 and examination terminals 6 and 7 are provided. Each computer is connected via the network line 4. Here, the clinician terminal 5 is mainly used by connecting to the electronic medical record server 1, the test terminal 6 is mainly used by connecting to the test server 2, and the test terminal 7 is connected to the test server 3 for use.

[0013] The following describes how to operate the system.
A specific example will be described.

The doctor A, who is a clinician, searches the clinician terminal 5 by patient name or the like in order to examine a patient.
The search is performed based on the patient's ID number, and the patient's chart is displayed on the display device of the clinician terminal 5.

The doctor A issues a test request necessary for the patient at the clinician terminal 5. In this case, the doctor A creates examination request information at the clinician terminal 5. This inspection request information is sent to the inspection server 2 via the network line 4.

[0016] The patient visits Doctor B for examination. Doctor B connects the examination terminal 6 to the examination server 2 and looks at the sent examination request information. Doctor B then performs the requested test on the patient. The doctor B inputs the result of the examination using the examination terminal 6 and stores the examination result in the examination server 2 as examination data. Further, the doctor B creates an examination report using the examination terminal 6. This inspection report is sent to the electronic medical record server 1 via the network line 4.

When a more detailed examination is required as a result of the examination, the doctor B can issue an examination request to another doctor from the examination terminal 6. In this case, Doctor B
Creates inspection request information using the inspection terminal 6. This inspection request information is sent to the inspection server 3 via the network line 4.

The patient visits the doctor C, and the doctor C connects the examination terminal 7 to the examination server 3 and views the sent examination request information. The doctor C then performs the requested test on the patient. The doctor C inputs the result of the test using the test terminal 7 and stores the result in the test server 3 as test data. Further, the doctor B creates an examination report using the examination terminal 7.
This inspection report is sent to the inspection server 2 via the network line 4 together with the electronic medical record server 1.

When the patient visits Doctor A again, Doctor A
The clinician terminal 5 refers to the two test results stored in the test servers 2 and 3,
The diagnosis is made and the treatment / prescription is determined by also referring to the past diagnosis result of the patient accumulated in the patient.

As described above, the doctor A operates the clinician terminal 5
By using only this, it is possible to send an inspection request to the inspection servers 2 and 3, and it is possible to refer to information on inspection results distributed and accumulated and managed in each inspection server. Further, the doctor B can refer to the test results of the test servers 2 and 3 using the test terminal 6.

Next, the association of data stored in each server will be described.

FIG. 2 is a diagram for explaining the association of the types of data stored in the storage devices in the electronic medical record server 1, the inspection servers 2 and 3 with each other.

In FIG. 2, accumulated data 1a is data stored in the electronic medical record server 1, accumulated data 2a is data stored in the inspection server 2, and accumulated data 3a is an inspection server 3 Is the data stored in the FIG. 2 shows the data stored and managed in each server for one consultation of one patient.

The accumulated data 1a in the electronic medical record server 1 includes diagnostic information A, test request information B, test report notice D, and test report notice G. Each of these pieces of information includes a patient-specific or chart identification number (or identification symbol). Therefore, these pieces of information are related by the identification number, and one piece of information can refer to another piece of information by the identification number. In addition,
The test report notifications D and G are for notifying the other servers that the test reports D and G have been input to the test server, respectively.

The stored data 2a in the test server 2 includes a test request notice B, test data C, test report D, test request information E, and test report notice G. Inspection request notification B
Is for notifying the inspection server 2 that the inspection request information B has been input to the electronic medical record server 1. The inspection request information includes a unique identification number (or identification code) for each request. The identification number is also given to the inspection request notification, the inspection data, the inspection report, the inspection report notification, and other related inspection request information for the request. Therefore, these pieces of information are related by the identification number, and one piece of information can refer to another piece of information by the identification number. Therefore, the inspection request information B, the inspection request notification B, the inspection data C, the inspection report D, the inspection report notification D, and the inspection request information E are related by the identification number of the inspection. Can be referred to.

The stored data 3a in the test server 3 includes a test request notice E, test data F, and test report G. As in the case of the stored data 2a in the inspection server 2,
The inspection request information E, the inspection request notification E, the inspection data F, the inspection report G, and the inspection report notification G are related by the identification number of the inspection, and certain information can refer to other information by the identification number.

As described above, the clinician uses the clinician's terminal 5 to refer to the diagnosis data and test request information of a specific patient from the data stored in the electronic medical record server 1 by associating the respective data as described above. And the inspection servers 2 and 3
Can refer to the data of each test. Further, according to the above-described example, the user of the inspection server 3 can refer to the inspection data C of the inspection server 2 associated therewith from the inspection request notification E.

FIG. 3 is a diagram showing a state in which an electronic medical record is displayed on the display device of the clinician terminal 5. The display device of the clinician terminal 5 displays information on the diagnosis 31, the test request 32, the test result 33 of the test request 32, the test request 34, the test result 35 of the test request 34, and the treatment / prescription 36. These pieces of information are created at different dates and times. In addition, these information 31 to 36
Occurs at each visit of the patient.

For the physician, the "diagnosis and test result" as information relating to diagnosis of the above information and the "test request and treatment / prescription" as medical action information to be given to the patient are displayed separately. It is easier to handle. In addition, it is preferable that the “diagnosis” and the “examination” supporting the “diagnosis” and the “diagnosis” and the “treatment / prescription” accompanying the “diagnosis” are displayed in correspondence with each other so that they can be recognized at a glance.

Therefore, in the present system, the diagnosis 31, the test result 33 of the test request 32, and the test result 35 of the test request 34
Is displayed on the left side of the display screen, and the inspection request 32, the inspection request 34, and the treatment / prescription 36 are displayed on the right side of the display screen. This makes it easy to distinguish between information related to diagnosis and information on medical practice performed on a patient.

The direction from the top to the bottom of the display screen (vertical direction) is taken as a time series, and a diagnosis 31, an examination request 32, an examination request 34, a treatment / prescription 36,
The inspection result 33 of the inspection request 32 and the inspection result 35 of the inspection request 34 are displayed. This makes it easier to understand the correspondence between each information.

As described above, the time-series flow and the classification of information can be easily understood.

Information such as inspection results 33 and 35 often includes image data, and has a large amount of information. With respect to such information, only the summary is displayed in the display of FIG. 3, and detailed information can be referred to by pointing to each summary (for example, moving the mouse cursor to the summary and clicking the mouse). To do.

The electronic medical record shown in FIG. 3 will be described in more detail. This chart is an example of one created when a patient suspected of having stomach cancer came to the hospital. Doctor A suspects stomach cancer through an interview or the like, and requests endoscopic examination.
A part of the patient's stomach is removed by endoscopy, and a pathological examination is performed for a more detailed examination.

The doctor A fills out a patient diagnosis (in this case, suspected gastric cancer, etc.) at the clinician terminal 5 (FIG. 3).
It is recorded in the part of the code | symbol 31 inside). Then, send a request for endoscopy. (Recorded in the portion indicated by reference numeral 32 in FIG. 3). After that, the endoscope inspection is completed and the result is obtained (recorded in the portion indicated by reference numeral 33 in FIG. 3). A request for a pathological examination is made based on the specimen removed by endoscopy. This examination request may be made by the doctor A or may be made by the doctor who has performed the endoscopy (recorded in the portion indicated by the reference numeral 34 in FIG. 3). In general, a pathological examination requires a period of several days.
Prescribes a drug that suppresses stomach acid (recorded at the portion indicated by reference numeral 36 in the figure). Thereafter, the result of the pathological examination is found (recorded in the portion indicated by reference numeral 35 in the figure), and the patient returns to the hospital to determine a formal diagnosis and prescription (reference numerals 31 and 36 in the figure).
Is recorded in the section).

FIG. 4 is a diagram showing a state where the inspection report information is displayed. In FIG. 3, the inspection results 33 and 35 are displayed as only the summary. By pointing at the character portion of “Endoscope inspection result” or “Pathological inspection result” in the display of FIG. 3, an inspection report as shown in FIG. 4 is displayed. FIG. 4 is an example of a report of an endoscope inspection result.

The doctor B performing the endoscopy uses the examination terminal 6 to confirm the examination request from the doctor A, performs an endoscopy on the patient, and describes an examination report as shown in FIG. Necessary image data is attached to the inspection report. In FIG. 4, when the user points to the portion indicated by reference numeral 41, an inspection image by the endoscope as shown in FIG. 5 is displayed.

In such an inspection image, it is possible to add a mark to a notable position (for example, an affected part).
Information (mainly characters) called annotation is embedded at an arbitrary position in the image, and is displayed simultaneously with the image. In FIG. 5, markings “# 1” and “# 2” are given. By pointing to these markings,
The information accompanying the image in FIG. 5 can be referred to. The marking and the image are stored mainly in the inspection server in association with different data. Therefore, the image and the marking can be displayed at the same time, or the image can be displayed without the marking.

The doctor B uses the examination terminal 6 to mark the position of the excised diseased part in the examination image,
Fill out the findings of the affected area.

The doctor B sends a pathological examination request to the pathological examination department. Doctor C confirms the examination request and performs a pathological examination. The doctor C can refer to the image, the annotation, and the information related thereto of the endoscopy shown in FIG.

The result of the pathological examination is input from the examination terminal 7 by the doctor C. The pathological test image in FIG. 6 and the pathological test report in FIG. 8 are stored in association with the annotation (marking) in FIG.

In FIG. 5, when the user points to the marking 51 (the marking marked "# 2" in the image), a screen as shown in FIG. 7 is displayed. The screen in FIG. 7 includes a selection unit 71 for a report of a pathological test and a selection unit 7
2 is displayed. Pointing at the pathological examination report selection section 71, a pathology report screen as shown in FIG. 8 is displayed. On this screen, the same operation as the screen of the endoscope inspection report in FIG. 4 can be performed. Also, when the selection unit 72 of the image of the pathological examination is pointed on the screen of FIG.
A related pathological image is displayed as shown in FIG.

[0043]

As described above, according to the present invention, the diagnostic information and the test result information can be displayed side by side on the display means, and the test request information and the prescription information can be displayed on the display means. By displaying the information on the right side of the information display, the correspondence of each information can be understood at a glance.

[Brief description of the drawings]

FIG. 1 is a configuration diagram showing an embodiment of an electronic medical record system of the present invention.

FIG. 2 is a view for explaining the mutual association of the types of data stored in the storage devices in the electronic medical record server and the inspection server in one embodiment of the electronic medical record system of the present invention.

FIG. 3 is a diagram showing a state in which an electronic medical record is displayed on a display device of a clinician terminal in one embodiment of the electronic medical record system of the present invention.

FIG. 4 is a diagram showing a state in which test report information is displayed on a display device of a clinician terminal in one embodiment of the electronic medical record system of the present invention.

FIG. 5 is a diagram showing a state in which an endoscopic examination image associated with the electronic medical record is displayed in one embodiment of the electronic medical record system of the present invention.

FIG. 6 is a diagram showing a state in which a pathological examination image associated with marking of an endoscopic examination image is displayed in one embodiment of the electronic medical record system of the present invention.

FIG. 7 is a diagram showing a state in which a selection screen is displayed when the user points the marking of the inspection image in the electronic medical record system according to the embodiment of the present invention.

FIG. 8 is a diagram showing a state in which a pathological examination report associated with marking of an endoscopic examination image is displayed in one embodiment of the electronic medical record system of the present invention.

[Description of Signs] 1; Electronic medical record server, 2, 3; Test server, 1a; Stored data in electronic medical record server 1, 2a; Stored data in test server 2, 3a; Stored data in test server 3, 4 Network line, 5; clinician terminal, 6, 7; test terminal, 31; display of diagnosis, 32; display of test request, 33, 35; display of test result, 34; display of test request, 36; Indication of prescription, 51; marking in inspection image.

Claims (1)

[Claims] At least one electronic medical record storage means storing medical record information of each patient; at least one test data storing means storing test result information of each patient; and storing at the electronic medical record storage means. And display means capable of displaying the data stored in the test data storage means, and the display means displays at least diagnostic information, test request information, test result information, and prescription information on a display surface. It is possible to display the diagnostic information and the test result information side by side in the vertical direction, and to display the test request information and the prescription information on the right side of the display of the diagnostic information and the test result information. An electronic medical record system characterized by: