JP2001028027A - Disease name processor - Google Patents

Abstract

PROBLEM TO BE SOLVED: To easily replace injury and disease names entered into a clinical record card with injury and disease names which are preferably entered into a receipt when injury and disease names are inputted to an office word processor for receipt generation. SOLUTION: The processor is provided with a 1st disease name database wherein data on diagnosed disease name that a doctor enters in a clinical consultation record by taking a diagnosis and disease name data for display are registered and a 2nd database wherein data of standard disease names to be entered into a receipt are registered; and an inputted disease name is retrieved from the 1st disease name database and is stored as clinical record data for every patient and the disease name corresponding to the stored disease name is retrieved from the 2nd disease name database and outputted as a disease name for receipt entry.

Description

DETAILED DESCRIPTION OF THE INVENTION

[0001]

BACKGROUND OF THE INVENTION 1. Field of the Invention The present invention relates to a disease name processing apparatus for outputting a disease name to a medical record or a receipt of a patient.

[0002]

2. Description of the Related Art In a medical institution, a doctor diagnoses a patient,
When a medical practice is performed, the contents are recorded in a medical record (hereinafter referred to as a medical record). The medical record describes the patient's condition, the chief complaint, the medical treatment performed such as the treatment and medication performed, and the name of the injured or illness that the physician assumed based on these.
In the past, it was obligatory to record the information on a paper chart and keep it for a predetermined period of time. In recent years, however, this has been replaced with a computer and electronically recorded and stored. In such an apparatus, the names of injuries and diseases used in the medical institution are registered in a database, and the data on the names of diseases retrieved from the database are recorded and stored as patient chart data.

[0003] On the other hand, a medical institution describes insurance medical practice performed on a patient in a medical reimbursement statement (hereinafter referred to as a “recept”), submits it to the insurance institution, and receives an insurance payment. I have. Then, an office processing device for outputting the receipt has become widespread. There, the performed medical treatment is input to the device based on the medical record and stored as so-called detailed data, and at the beginning of the next month, the medical treatment for the previous month is put together on a receipt paper. At that time, the claim is required to include the name of the injury or illness on which the medical practice was performed. For example, in the case where a medicine a is prescribed for the treatment of the disease A and calculated, the disease A is described in the disease name column of the claim. If there is a medication or the like in which the name of the corresponding illness is not described, the prescription may be excluded from the insurance payment or the receipt itself may not be accepted.

[0004]

Therefore, in a business processing apparatus for preparing a receipt, the name of the patient's injury or illness is also input and stored based on the medical record. For this purpose, the apparatus has a database in which the names of injuries and diseases that can be described in the receipt are registered. Then, the data of the name of the illness retrieved from the database is stored as the detailed data of the patient. However, the names of the injuries and diseases written by the doctor based on the diagnosis do not always match the names of the injuries and diseases that are desirably described in the claim. For example, suppose that a physician, as a result of a diagnosis, considers the patient's disease name as a viral cold and enters it in a medical chart. On the other hand, it is desirable to describe the epidemic cold in the claim. In some cases, the same epidemic cold may be described as a cold in the medical record. This is because the names of injuries and illnesses that doctors determine medically and epidemiologically appropriate and recorded in medical records for treatment are different from the names of illnesses for insurance claims.

[0005] Therefore, when a doctor or an operator inputs a disease name into an office processing device for preparing a receipt, the name of the disease or disease described in the medical record is replaced with the name of the disease or disease that is desirably described in the receipt. Had to enter. According to the above-described example, even if the patient's disease name is described in a viral cold or a cold and a medical chart, any of the names is replaced with the epidemic cold and input to the business processing device. As described above, it is necessary to enter the information in consideration of the correspondence between the name of the injury and the disease described in the medical record and the name of the injury and the disease described in the claim.

[0006] In general, the range of names of injuries handled varies depending on medical institutions or medical departments.
In addition, there is a tendency that, as the level of specialization increases, the names of the wounds and diseases are set and described in the medical chart. Therefore, the wound and disease name database for creating medical charts has unique registration contents for each medical institution and medical department so that doctors can easily use it, and the contents are significantly different from the wound and disease name database for creating claims. . As described above, since the injury and disease name database for creating the medical record and the injury and disease name database for creating the claim were constructed completely independently, no mutual correspondence between the injury and disease names was taken. For this reason, a doctor has not input a disease name stored in the patient's chart data as a disease name data described in a receipt.

[0007]

SUMMARY OF THE INVENTION The present invention relates to a disease name processing apparatus for creating a medical record by inputting a disease name diagnosed by a doctor, comprising an input means, an output means, and a medical treatment input by the input means. A first storage unit for storing data, a first disease name database in which data of a diagnosis disease name and a disease name data for display registered by a doctor and recorded in a medical record are registered, and a disease name inputted by the input means. First search means for searching from the first disease name database, first storage control means for storing and controlling disease name data searched by the search means in the first storage means for each patient; Output control means for controlling the output of the diagnostic disease name data stored in the storage means as a medical record to the output means,
The output control means determines whether or not the data stored in the first storage means includes the disease name data for display, and the determination means includes the disease name for display. When the determination is made, the disease name for display is displayed and output in place of the data of the diagnosis disease name, and further, a second database in which data of a standard disease name described in a receipt is registered, and A second search unit for searching the second database, and a correspondence between a disease name of the first database and a disease name of the second database is registered in at least one of the databases; The second search means searches the second database using the disease name data searched by the first search means, and searches for the disease searched from the second database. By outputting the data, it is to solve the above problems.

[0008]

DESCRIPTION OF THE PREFERRED EMBODIMENTS FIG. 1 is a block diagram showing the configuration of a chart creation device 10 which is an example of a disease name processing device. In the present embodiment, the chart creation device 10 is connected to a medical computer 30 via a LAN line 20. The medical calculator 30 is a business processing device that performs a so-called medical business that creates and issues a receipt. The chart creation device 10 includes a control device 11 that executes processing according to a program stored in advance.
An input device 12 represented by a keyboard, a display device 14 such as a CRT and a printer 15 as output devices,
An output control device 16 for controlling the output so as to display or print data on these output devices, and a communication device 19 for sending data to the outside are provided.

[0009] The chart creating apparatus 10 further includes two databases of names of injuries and diseases. In the following, the names of injuries and illnesses will be simply referred to as disease names. There is a diagnostic disease name database 17 as a first disease name database, and a resected disease name database 18 as a second disease name database. The diagnostic disease name database 17 is a database in which, as a result of a doctor's diagnosis of a patient, a disease name that is likely to be given as the most appropriate is registered. Therefore, this diagnostic disease name database 17 is usually registered mainly by the medical institution where the chart making apparatus 10 is placed, or by the medical department or the doctor's specialty, mainly on the disease names that are likely to be used. It is. On the other hand, the disease name database 1
Reference numeral 8 denotes a database in which standard disease names that are desirably described in a medical fee statement, a so-called “claim name” column, are registered.

FIG. 2 shows an example of the structure of a record in each database. FIG. 2A shows the diagnostic disease database 1.
7 shows a record configuration, and the beginning is a unique diagnostic disease name code 41 for identifying each record. The diagnostic disease name code 41 can be arbitrarily set by the user as an easy-to-remember code combining numbers and kana so as to be easy to use when inputting a disease name. The disease name (kanji) 43 is data in which the disease name is written in kanji, and can also be arbitrarily set by the user. The name of the disease in kanji is output to the medical chart.
The disease name (kana) 44 is data in which the disease name is written in kana, and is used when the user searches for a similar disease name. The display disease name 46 is a disease name for screen display used when inputting the disease name or displaying the contents of the medical chart on the screen. Normally, the displayed disease name 46 is not registered and thus the data is empty. However, when the doctor enters the disease name in the consultation room, the diagnosis disease name that the patient does not want to see directly is separately from the disease name (Kanji) 43. It is something to set. The flag 45 indicates the presence or absence of the displayed disease name 46. The disease name code 42 indicates a disease name in the disease name database 18 corresponding to the disease name.

FIG. 2B shows the record structure of the resected disease database 18. As shown in FIG. The head is a resected disease name code 51 for identifying each record. The disease name code 51 is a unique code used when a medical practice is input in the medical computer 30 described later, and is assigned according to the same rules as other medical practices, for example, medical treatment codes representing treatments and medicines. The name of the disease name 51 is completely independent from the name of the diagnosis name 41. The master code 52 is a code based on a code assigned to a standard disease name, in this case, a disease name published in a standard illness list collected by a public organization according to the International Classification of Diseases (ICD-10). The disease name (Kanji) 53 and the disease name (Kana) 54 are also written in Kanji or Kana, respectively, in accordance with the description of the standard injury and disease name list described above, and the standard disease names that are desirably described in the receipt are described. Data. Therefore, this disease name (Kanji) 53
The disease name (kana) 54 does not always match that of the diagnostic disease name database 17.

As described above, the disease name data in the diagnostic disease name database is associated with the disease name in the disease name database 18 via the disease name code 42. However, in the resected disease name database 18, only one disease name data having a certain master code is registered in principle, but in the diagnostic disease name database 17, further subdivided disease names are registered and have the same resected disease name code 42. A plurality of disease name data may be registered. That is,
The correspondence between the disease names in the diagnostic disease name database 17 and the disease names in the rescue disease name database 18 is not limited to one-to-one, but may be many-to-one. As a result, the corresponding disease name in the disease name database 18 can be directly referenced from the diagnostic disease name database 17.

Returning to FIG. 1, the medical computer 30
A communication device 33 that communicates with the chart creation device 10 via the N line 20; a control device 34 that performs processing according to a program stored in advance; a storage device 35 that stores detailed data described in a receipt; and an input device such as a keyboard 31
And an output device 32 including a display device and a printer.

Next, the operation of the embodiment will be described with reference to the flow chart of FIG. First, the doctor inputs a disease name determined by diagnosing a patient, in this case, a diagnosis disease name, from the input device 12 (step S41). At that time, the name may be directly input using the diagnostic disease name code 41 representing the disease name,
It is also possible to search for a disease name in kana notation, display a list, and select and input one of them. When the disease name is input, the control device 11 receives it and searches the diagnostic disease name database 17 by the disease name code or the like (S
42). Then, when the matching record is read, the storage control is performed on the storage device 13 as the disease name data of the patient (S43). That is, among the medical record data stored for each patient in the storage device 13, the disease name data is additionally stored as a part of the medical record data related to the patient.

The control unit instructs the output control unit to display the disease name (kanji) 43 of the stored record in the chart displayed on the screen of the display device 14 (S4).
4). At this time, it is first determined whether or not the display disease name 46 is registered in the same record with reference to the flag 45. If the display disease name 45 exists, the display disease name 46 is displayed on the screen instead of the disease name (Kanji) 43. It is displayed. This is, for example, the name “epidemic cold”
Is registered in the disease name (Kanji) 43, while “Kaze” is registered in the display disease name 46, it indicates that the disease name “Kaze” is displayed on the screen. With this, when you enter a disease name in front of the patient in the examination room, by displaying the disease name that is easy for the patient to understand,
It is intended to make it easier for a doctor to explain a medical condition to a patient.

Further, the control device 11 extracts the resected disease name code 42 from the record retrieved and read from the diagnostic disease name database 17, and this time, the resected disease name code 42 is extracted.
Is used to search the rescue disease name database 18 (S45). That is, for the diagnostic disease name input from the input device 12, the corresponding disease name for claim description is retrieved from the disease name database 18. Then, the searched disease name data is transmitted and output to the medical computer 30 using the communication device 19. At this time, disease name data for describing the receipt is transmitted together with the patient identification data indicating the patient (S46).

On the other hand, in the medical computer 30, the LAN line 2
Since the communication device 33 receives the disease name data transmitted through the communication device 33, the control device 34 receives the disease name data together with the patient identification data transmitted along with the disease name data, and specifies the detailed data of the patient indicated by the patient identification data. The received disease name data is stored and controlled in the storage device 35. Since this disease name data is a disease name that can be described in the receipt read from the receipt disease name database 18, when the patient's receipt is output from the output device, it can be output as it is to the disease name column of the receipt.

As described above, the input of the name of the disease to be described in the medical chart and the search and output of the name of the disease to be described in the claim are performed in this order, but are not necessarily performed in a continuous manner as described above. It doesn't matter. For example, the medical record creation device 10 can send disease name data for describing a receipt to the medical computer 30 in accordance with an instruction from the input unit. In that case, once the disease name data of the diagnostic disease name is additionally stored and displayed as a part of the patient's medical record data stored in the storage device 13 shown in steps S43 and S44, the processing is once performed. finish. Thereafter, when an instruction is received from the input device 12, the disease name data of the patient, that is, the diagnosis disease name stored in the storage device 13 is read out, and the disease name database 18 is searched using the disease name code 42.
That is, a disease name for describing the claim corresponding to the stored diagnosis disease name is searched. Then, the obtained disease name data is transmitted to the medical computer 30 using the communication device 19.

By the way, in the above-described embodiment, the medical chart creating device 10 and the medical computer 30 are separately configured and are connected by a communication line. However, these can be configured as an integrated device. FIG. 3 shows the configuration of another embodiment. 1 are denoted by the same reference numerals. FIG.
In the device of the first embodiment, the medical data input by the doctor as described in the medical record is stored in the storage device 1 as the first storage device.
3 and the so-called detailed data described in the receipt are separately stored in a storage device 35 as a second storage device.

Then, when a diagnostic disease name is input from the input device 12, the control device 11 receives it, and first searches the diagnostic disease database 17 based on the disease name code or the like. Then, when the matching disease name data is read out, it is additionally stored as a part of the medical record data relating to the patient among the medical record data stored for each patient in the storage device 13. Next, the control device 11 searches the disease name database 18 this time using the disease name code 42 of the stored disease name data. That is, the diagnostic disease name input for describing the medical record is converted into a disease name for describing the receipt. Then, the storage device 35 is controlled so as to store the searched disease name data in addition to the detailed data of the patient.

As described above, in the apparatus according to the embodiment, when a doctor diagnoses a patient when he / she treats it and enters the determined disease name into an electronic medical record and stores it, the disease name described in the receipt for the patient is correspondingly entered. Automatically determined,
It is memorized. Moreover, the disease name is not a special disease name described in the medical record, but a standard disease name that is desirably described in the receipt.

[0022]

According to the present invention, when a physician inputs a disease name determined by diagnosing a patient to be described in a medical chart, the disease name to be described in the receipt for the patient is automatically determined accordingly. Is output. Accordingly, it is not necessary to input the disease name into the medical computer again in consideration of the correspondence between the name of the disease described in the medical record and the name of the disease described in the receipt, so that the burden on the operator is reduced.

Further, since there is no need to be aware of the disease name to be output on the receipt, the doctor can freely input the diagnosed disease name into the medical chart.

The disease name output for the receipt is not a specialized disease name described in the medical record, but a standard disease name that is desirably described in the receipt. Therefore, when the patient's claim is output from the output device, it can be output as it is in the disease name field of the claim.

[Brief description of the drawings]

FIG. 1 is a block diagram illustrating a configuration of an embodiment.

FIG. 2 is a diagram showing a record configuration of a disease name database in the embodiment.

FIG. 3 is a block diagram showing a configuration of another embodiment.

FIG. 4 is a flowchart showing the operation of the embodiment.

[Explanation of symbols]

DESCRIPTION OF SYMBOLS 10 Medical chart preparation device 11 Control device 12 Input device 13 Storage device 17 Diagnosis disease database 18 Recess disease database 19 Communication device 2
0 LAN line 30 Medical computer 33 Communication device 34 Control device 35 Storage device

Claims (4)

[Claims] 1. A disease name processing device for creating a medical record by inputting a disease name diagnosed by a doctor, comprising: input means, output means, and first storage for storing medical data input by the input means. Means, a first disease name database in which data of a diagnosed disease name which is diagnosed by a doctor and described in a medical record and disease name data for display are registered, and a disease name inputted by the input means is searched from the first disease name database. First search means for performing the search, first storage control means for storing and controlling the disease name data searched by the search means in the first storage means for each patient, and diagnosis disease names stored in the first storage means Output control means for controlling the output data as a medical record to the output means, wherein the output control means includes the disease name data for display in the data stored in the first storage means. Means for determining whether or not the disease name for display is included by the determination means, and the disease name for display is displayed and output instead of the data of the diagnostic disease name, and , A second database in which data of standard disease names described in the receipt are registered, and second search means for searching the second database, wherein the disease names of the first database and the second database are provided. The correspondence with the disease name is registered in at least one of the databases, and the second search means searches the second database based on the disease name data searched by the first search means. A disease name processing apparatus for outputting data of a disease name retrieved from the second database. 2. Registering reference information from a disease name in the first database to a disease name in the second database corresponding to the disease name in the first database, and the second search means stores the reference information in the first database. 2. The disease name processing apparatus according to claim 1, wherein the search means receives the disease name data retrieved from the first database, and retrieves the second database based on the reference information of the disease name data. 3. The disease name processing apparatus according to claim 1, wherein the correspondence between the disease name in the first database and the disease name in the second database includes a many-to-one relationship. 4. A second storage means for storing data relating to the patient's receipt, and a second storage control means for storing and controlling the medical data and the disease name data relating to the receipt in the second storage means for each patient. And the second storage control means stores the disease name data retrieved and output by the second retrieval means as the disease name described in the patient's receipt.
4. The disease name processing device according to claim 1, wherein the storage is controlled by the storage means.