JP2001034690A - Electronic medical record device - Google Patents

Abstract

PROBLEM TO BE SOLVED: To give a prescribed restriction on the change of the recorded content of an electronic medical chart and to prevent the chart from being rewritten except in a case that a proper reason such as a simple filling error exists. SOLUTION: In the electronic medical record device, rewriting is inhibited when a person who is to rewrite recorded medical treatment information is not the approver of medical treatment information (S55: NO) and when a medical treatment date selected for rewriting recorded medical treatment information is before a change possible date (S57: NO).

Description

DETAILED DESCRIPTION OF THE INVENTION

[0001]

[0001] 1. Field of the Invention [0002] The present invention relates to an electronic medical record apparatus, and more particularly, to an electronic medical record apparatus that imposes certain restrictions on changes in recorded medical information.

[0002]

2. Description of the Related Art There has been provided a so-called electronic medical record apparatus in which medical information is digitized and recorded on a recording medium such as a hard disk, and is displayed on a display or printed out as necessary. In electronic medical record devices,
The medical treatment information is recorded by a doctor or the like at the time of medical examination / medical treatment, as in the case of a paper chart. It is approved by a person having authority such as a doctor. The purpose of using the recorded medical information is the same as in the case of paper charts, and doctors can refer to past prescriptions and medical histories for patients to refer to this prescription,
The test results are used to understand the medical condition and to verify the effect of treatment.

[0003]

The purpose of using an electronic medical record is the same as that of a paper medical record, and has a function as a medical condition of a patient and a history of treatment. It is necessary to make sure that it cannot be overwritten unnecessarily, except in the case of an incorrect entry or the like. An object of the present invention is to impose certain restrictions on changes in the recorded contents of an electronic medical record so that rewriting cannot be performed unless there is a legitimate reason such as a simple entry error.

[0004]

The following configurations are based on the premise that recording and rewriting of medical information is performed with respect to recording of a certain medical day of a certain patient. In other words,
It is assumed that the medical care information can be selected on a patient basis and on a medical care day basis. An electronic medical record device according to claim 1, wherein a changeable date calculation unit that calculates a date that is a predetermined number of days before the system date as a changeable date of medical information, and a changeable date storage unit that updates and stores the calculated changeable date. Medical information storage means for storing medical information, selecting means for selecting a medical treatment date for which medical information is to be input, input mode instructing means for setting an input mode of medical information, and medical care for inputting medical information. If the date is selected and the medical information input mode is commanded, the selected medical treatment date is compared with the changeable date before and after the changeable date stored in the changeable date storage means, and if the changeable date is a later date, Medical information input management means for prohibiting the setting of the medical information input mode and permitting the setting if the date is not a later date. That is,
This device prohibits rewriting when the medical treatment date selected for rewriting the recorded medical information is earlier than the changeable date. If the medical treatment date selected as the medical information input target and the changeable date are the same, whether to permit or prohibit the change is a matter of choice in device design. That is, the medical information input management means also includes a configuration in which the setting of the medical information input mode is permitted when the changeable date is the earlier date and prohibited when the change date is not the earlier date. In the electronic medical record apparatus according to claim 2, the medical information input management means according to claim 1 prohibits input of medical information or permits input instead of prohibiting or permitting setting of the medical information input mode. It is characterized by. That is, in the first aspect, rewriting is prevented by prohibiting the setting of the medical information input mode (prohibiting the transition to the medical information input screen and the opening of the medical information input window). Rewriting is prevented by prohibiting the input of medical information. For example, there is no input-only screen called a medical information input screen or an input-only window called a medical information input window, and the apparatus is configured to input medical information on a medical information screen or the like. According to a third aspect of the present invention, in the electronic medical record apparatus, the changeable date storage means of the first or second aspect compares the changeable date stored before and the changeable date calculated by the changeable date calculation means. Then, only when the calculated changeable date is a later date, the previous changeable date is updated with the calculated changeable date. If the system date is returned to a date before the actual date, the calculated changeable date is ignored because the calculated changeable date is earlier than the previously stored changeable date. Is done. That is, the previous changeable date is not updated with the calculated changeable date. In this case, the availability of the medical information input mode (or medical information input) by the medical information input management means is determined based on the previous changeable date that has not been updated. Therefore, by returning the system date, the medical treatment date of the medical information input target cannot be set to a date later than the changeable date. According to a fourth aspect of the present invention, there is provided the electronic medical record apparatus according to any one of the first to third aspects, further comprising a unit for storing an approver of the medical information in association with the medical information, It is characterized in that the condition for permitting is that the person who has selected the medical day of the information input target and the approver of the medical information of the input target are the same.
According to a fifth aspect of the present invention, there is provided the electronic medical record apparatus according to any one of the first to fourth aspects, wherein the changeable date calculation means performs the calculation when the system is started. When the system is constantly operating, for example, it is also possible to configure so as to perform the calculation at a predetermined time.

[0005]

FIG. 1 shows a configuration example of an electronic medical record apparatus according to an embodiment. As shown, the electronic medical record device is
It includes a control device 20, a keyboard 11, a mouse (or other known pointing device) 12, a display 13, and a storage device 30. The control device 20 includes a program ROM, a working RAM, an MPU, a video RAM, and the like. Functionally, a system control unit 21 having a control function of the entire apparatus, a display control unit 24 having a display control function of the display 13, and a file recording / reproducing unit 2 having a function of reading / writing each file in the storage device.
3. It has a system clock 26. The storage device 30 is configured as a device having a recording medium such as a hard disk, for example. The storage device 30 is provided with a medical care information file 31. It should be noted that the storage device 30 also has other files other than the medical care information file 31, but is not shown because it is not related to the gist of the present invention.

The medical information file 31 has the tables shown in FIGS. 6 and 7. The medical information changeable date table stores medical information changeable dates (also referred to simply as “changeable dates”). That is, when the electronic medical record apparatus is activated, the system control unit 21 reads the system date from the system clock 26 and obtains a date a predetermined number of days (for example, 30 days) before the read system date as a changeable date.

Next, the changeable date (new) obtained as described above is compared with the changeable date (previous) stored in the medical treatment information changeable date table, and the changeable date obtained this time is compared. Only when the date (new) is a date that is later than the changeable date (previous) stored in the medical information changeable date table, the changeable date obtained this time (new) and the previous changeable date To update. If the changeable date (new) obtained this time is not a date after the previously stored changeable date, the update is not performed and the previous changeable date is kept stored as it is. The above processing is shown in the flowchart of FIG. The update of the medical information changeable date table, that is, the calculation of the changeable date, may be performed when the electronic medical record device is started. For example, in an environment where the electronic medical record device is not turned off, the calculation and update at a predetermined time every day are performed. May be performed.

[0008] The patient table stores the name and code of each patient in association with the patient ID. Each user (doctor, etc.) who uses the electronic medical record device is stored in the user table.
Is stored in association with the user ID. The approval right is the authority to approve the contents of the medical record, and for each medical record of each patient on each medical treatment day, the user ID of the user who approved the medical record is recorded in association with the medical record ( Refer to the medical information table). Further, the approval date and time is recorded as the recording date and time of the medical record (see the medical information table). When rewriting the medical record of a certain patient on a certain medical treatment date at a later date,
The approver ID of the medical record is checked with the user ID of the user who performs rewriting, and rewriting is permitted only when both match. That is, rewriting is permitted only to the authorized user.

[0009] In the medical information table, the patient ID, the above-mentioned approver ID, the consultation date and time, and the recording date and time are stored in association with the medical information ID. In the medical treatment table, the medical treatment information ID, the deletion flag, the recording date and the details of the medical treatment (substantial contents of the medical treatment information such as the chief complaint, the current medical history, findings, previous illness, and family history) are included in the medical treatment ID. It is stored in correspondence.

When a certain examination day (medical treatment day) of a patient displayed on the medical treatment information screen of FIG. 2 is selected with a pointing device (FIG. 2 shows a state in which the medical record on April 3, 1999 is selected). Medical information ID (in this case, “medical treatment”) associated with both the patient ID of the patient and the selected medical examination date (in this case, April 3, 1999) in the medical information table. Information ID = 3 "; see the medical treatment information table).

After the medical information ID is specified, when the medical information input button in the medical information screen of FIG. 2 is pressed with a pointing device, the information of the medical contents table is read out according to the specified medical information ID, and 3 is displayed on the medical information input screen (FIG. 3). However, the following restrictions are imposed on the transition to the medical information input screen (FIG. 3), that is, on the setting of the medical information input mode.

First, an approver ID (in this case, "approver ID = 2"; see the medical information table) associated with the specified medical information ID (in this case, "medical information ID = 3") is stored. , The user ID of the current user is checked. Note that the user ID of the current user is
It is assumed that password, fingerprint collation, voiceprint collation, etc. have been determined. As a result of the above check, if the current user ID and the approver ID are not the same (step S5 in FIG. 5).
5: NO), an error message is displayed to the effect that "rewriting of medical information is not permitted for anyone other than the approver" (step S6).
1). That is, transition to the medical information input screen (FIG. 3) (= setting of the medical information input mode) is not performed.

In step S55, the ID of the current user
If the ID is the same as the approver ID, then the recording date and time associated with the specified medical information ID (in this case, “medical information ID = 3”) and the medical information changeable date table A check is made before and after the read changeable date. As a result, if the date of the recording date and time is not a date after the changeable date (step S57: NO), an error display is displayed indicating that rewriting is not permitted because the changeable period has elapsed (step S63). That is, also in this case, the transition to the medical information input screen (FIG. 3) (= setting of the medical information input mode) is not performed.

If the date of the recording date and time is a date after the changeable date in step S57, the transition to the medical information input screen of FIG. 3 is permitted (step S59), and the medical record of the selected medical day is stored. Rewriting becomes possible. It should be noted that a deletion flag is set for the medical information deleted by rewriting on the medical information input screen (see the medical contents table). That is, the deleted medical information is stored as data. The above processing is shown in the flowchart of FIG.

The medical information screen of FIG. 2 referred to in the above description is a screen for displaying the recorded medical information for each medical day. Further, the medical information input screen of FIG. 3 is a screen for selecting desired medical information from among displayed on the medical information input field by selecting in the medical information selection field and inputting its contents. The medical care information input and confirmed in this input field is recorded in the above-mentioned medical care content table.

[0016]

In each claim of the present invention, if the medical treatment date selected for rewriting the recorded medical information is a date earlier than the changeable date, the rewriting is prohibited. Can be rewritten only within a certain period of time (for example, 30 days). As this period, a period that is sufficient to correct a simple description error or the like and is appropriate to prevent rewriting of a medical record without a justifiable reason is selected. In the electronic medical record device of claim 3, the changeable date storage means stores the changeable date stored before,
By comparing before and after the newly calculated changeable date, only when the calculated changeable date is a later date, the previous changeable date is updated with the calculated changeable date. Therefore, if you set the system date back to a date before the actual date,
Previous changeable date is not updated. Therefore, an attempt to return the system date to make the medical treatment date of the medical information input target a date later than the changeable date does not work. In the electronic medical record device according to the fourth aspect, only a person who has the authority to approve the medical record is permitted to be rewritten.

[Brief description of the drawings]

FIG. 1 is a block diagram showing a configuration of an electronic medical record device according to an embodiment.

FIG. 2 is an explanatory diagram illustrating a medical information screen.

FIG. 3 is an explanatory view exemplifying a medical information input screen.

FIG. 4 is a flowchart showing a procedure for updating a changeable date.

FIG. 5 is a flowchart showing a procedure for determining whether or not a transition to a medical information input screen is possible.

FIG. 6 is an explanatory view exemplifying a medical information changeable date table, a patient table, and a user table;

FIG. 7 is an explanatory diagram illustrating a medical care information table and a medical care content table.

[Explanation of symbols]

 31 Medical treatment information file

Claims (5)

[Claims] 1. A changeable date calculation means for calculating a date a predetermined number of days before a system date as a changeable date of medical treatment information, a changeable date storage means for updating and storing the calculated changeable date, and The medical information storage means to be stored, the selecting means for selecting a medical day for which medical information is to be input, the input mode instructing means for setting the medical information input mode, and the medical day for which the medical information is to be input are selected. When the medical information input mode is instructed, the selected medical treatment date is compared with the changeable date before and after the changeable date stored in the changeable date storage means, and if the changeable date is a later date, the medical treatment is performed. An electronic medical record apparatus, comprising: a medical information input management unit that prohibits setting of an information input mode and permits the setting if it is not a later date. 2. The medical information input management means according to claim 1, wherein the medical information input management means prohibits or permits input of the medical information instead of prohibiting or permitting the setting of the medical information input mode. Electronic medical record device characterized by the following. 3. The changeable date storage means according to claim 1, wherein the changeable date storage means compares the changeable date stored before and the changeable date calculated by the changeable date calculation means. An electronic medical record apparatus characterized in that a previous changeable date is updated with a calculated changeable date only when the calculated changeable date is a later date. 4. The medical information input management means according to claim 1, further comprising means for storing an approver of the medical information in association with the medical information. An electronic medical record apparatus characterized in that a condition that a person who has selected a medical treatment day and an approver of the medical information to be input is the same is a condition for permission. 5. The electronic medical record device according to claim 1, wherein the changeable date calculation means performs calculation when the system is started.