JP2001043293A - Care card device - Google Patents

Abstract

PROBLEM TO BE SOLVED: To easily register a routine sentence and to prepare optimal routine sentence candidates for each patient in a care card device. SOLUTION: Conecerning the care card device for selecting medical care information displayed in a medical care information display area inside a chart display picture and/or medical care information input column inside a medical care information input picture and recording it in a routine sentence file 303, this device reads sentences in the medical care information of a patient in the past and records them in a personal routine sentence file 302 for this patient.

Description

DETAILED DESCRIPTION OF THE INVENTION

[0001]

[0001] The present invention relates to a function of transferring medical information selected in a fixed phrase selection field to a medical information input field,
The present invention relates to an electronic medical record device having a function of recording medical information input from a medical information input column in a medical information data file.

[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 recording of medical information is performed by a doctor or the like at the time of medical examination / medical treatment, as in the case of a paper chart. In addition, 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 patient medical histories for patients to refer to the current prescription, and refer to examination results to determine medical conditions. Understand and verify treatment effects.

[0003] In the electronic medical record apparatus, in order to reduce the trouble of inputting medical information, a medical text information input screen is provided with a standard text selection field and a medical information input field. A candidate is displayed, and a fixed phrase selected from the candidates is transcribed to a medical information input box (currently selected (= keyboard focused) medical information input box). That is, there is an electronic medical record device in which the frequently used texts are registered in advance as fixed texts, thereby reducing the trouble of inputting the texts one by one.

[0004]

The registration target of the above-mentioned fixed text is a frequently used text, but it is difficult to accurately estimate the usage frequency of various and various texts used in the medical record. Each doctor is different. For this reason,
The above-described electronic medical record apparatus is designed so that a doctor who is a user registers a fixed phrase. However, it is not desirable for a busy doctor to perform a task other than the original task of “registration of fixed phrases” between medical examinations and medical treatments. SUMMARY OF THE INVENTION It is an object of the present invention to make it possible to easily register a fixed phrase.

[0005] The frequency of use of the sentences used in the medical record, which is a candidate for registration of the above-mentioned fixed sentences, differs not only from doctor to doctor but also from patient to patient. It can be difficult to do so. It is an object of the present invention to be able to prepare optimal fixed phrase candidates for each patient.

[0006]

According to a first aspect of the present invention, there is provided an electronic medical record apparatus for transferring medical information selected in a fixed phrase selection field to a medical information input field, and for transferring medical information input from the medical information input field. A selection unit for selecting the medical information in the medical information display area and / or the medical information in the medical information input column, and a medical information selected by the selecting unit. It is characterized by having fixed form sentence recording means for recording in a fixed form file, and candidate display means for displaying each medical information recorded in the fixed form file as a selection candidate in the fixed form selection column. According to a second aspect of the present invention, there is provided the electronic medical record apparatus according to the first aspect, wherein the fixed phrase recording unit performs recording in response to an input from an input unit for instructing recording of the fixed phrase. In other words, the electronic medical record device according to the first and second aspects is a device that selects the medical information displayed in the medical information display area and / or the medical information input field and records the selected medical information in the fixed phrase file. The electronic medical record device according to claim 3 has a function of transferring the medical information selected in the fixed phrase selection field to the medical information input field, and a function of recording the medical information input from the medical information input field in the medical information data file. Creating means for creating a personal fixed phrase file for the selected patient; and medical information transfer means for reading past medical information of the patient from the medical information data file and transferring it to the personal fixed phrase file. Candidate display means for displaying each medical information transcribed to the personal fixed phrase file as a selection candidate in the fixed phrase selection field.
According to a fourth aspect of the present invention, in the electronic medical record apparatus according to the third aspect, there is further provided a deletion means for deleting the personal fixed phrase file when the selection of the patient is released.
According to a fifth aspect of the present invention, in the electronic medical record apparatus according to the third or fourth aspect, when the patient is accepted at the visit window, the creating means creates a personal fixed phrase file of the patient. In other words, the electronic medical record device according to claims 3 to 5 reads out the text in the past medical treatment information of the patient,
This is a device for recording in a personal fixed phrase file for the patient.

[0007]

DESCRIPTION OF THE PREFERRED EMBODIMENTS FIG. 1 shows the configuration of an electronic medical record apparatus according to an embodiment.
(B) shows a case of a network configuration. FIGS. 2 to 4 are explanatory diagrams showing examples of the table configuration of each file stored in the auxiliary storage device 30 of FIG. FIG. 5 is an explanatory diagram illustrating a medical information input screen, and FIG. 6 is an explanatory diagram illustrating a medical chart display screen. FIG. 7 is a flowchart showing a procedure for registering a fixed phrase on the medical care information input screen, FIG. 8 is a flowchart showing a procedure for registering a fixed phrase on the chart display screen, and FIG.
Is a flowchart showing a procedure for creating a fixed phrase from the medical information of the selected patient and recording it in the temporary fixed phrase master table.

The electronic medical record apparatus according to the embodiment includes an input device 11 such as a keyboard, a pointing device 12 such as a mouse, a display device 13 such as a CRT and a liquid crystal display,
CPU 20 that performs control described below in addition to system control, file operation, display device control, etc., RAM used as a work area in various processes executed by the CPU 20
21, a ROM 22 storing a program to be executed by the CPU 20, an auxiliary storage device 30 such as a hard disk storing various files including the illustrated files
And so on. When the electronic medical record device is configured as a network, the auxiliary storage device 30 is provided in a server.

A medical information input data file in which the input medical information is stored in the auxiliary storage device 30 in association with a patient (patient ID), a medical examination date (medical history ID), and a type (medical information definition ID). 301, a medical information definition master file 304 in which information defining an input area width, an input area height, a data type, and a data name for each type of medical information is stored in association with each other. The patient consultation history file 305 stored for each case, the fixed form master file 303 in which the fixed form is stored in association with the type of medical information (medical information definition ID), and the fixed form is the type of medical information (medical information definition) A file such as a temporary fixed phrase master file (= personal fixed phrase file according to claims 3 to 5) 302 temporarily stored in association with the ID) and the patient is stored. Here, the fixed phrase master file 303
Is a file prepared by the device of the first example corresponding to claims 1 and 2, and the temporary fixed phrase master file 302 is a file prepared by the device of the second example corresponding to claims 3 to 5. Specific examples of each file are shown in FIGS.

A first example of an electronic medical record device corresponds to claims 1 and 2. In the electronic medical record device of the first example, the medical information input screen (FIG. 5) is selected (=
The medical information displayed in the medical information input field (with keyboard focus) or the medical information displayed in the selected (= keyboard focused) medical information display area of the chart display screen (FIG. 6). Information is recorded in the fixed phrase master file 303 as a fixed phrase. FIG. 7 shows a procedure for registering a fixed phrase on the medical care information input screen, and FIG. 8 shows a procedure for registering a fixed phrase on the chart display screen.

The procedure shown in FIG. 7 is started by the transition to the medical information input screen, and the medical information input screen is displayed (S).
01). The medical information star data is read from the medical information definition master file 304, and the fixed phrase master data is read from the fixed phrase master file (S0).
3). Next, as shown in FIG. 5, a list of medical information name candidates is displayed in the medical information selection field (S05),
A list of fixed phrase candidates is displayed in the fixed phrase selection field for each type of medical care information (S07).

In step S09, an event is on standby. When the fixed phrase creation button (see FIG. 5) is clicked, it is selected (indicated by a thick line frame in FIG. 5).
There is a medical information input column (S11: YES), the data type of the medical information to be input in the medical information input column is a sentence type (S13), and there is medical information in the medical information input column (S15: YES). ), On the condition that the medical information having the same content as the medical information is not registered in the standard sentence master file 303 (S17: YES), the medical information is registered in the standard sentence master file (S19).

If another event has occurred as a result of the standby at step S09, processing corresponding to the other event is performed (S25). When an end event has occurred (S21: YES), the medical care information input screen is closed (S23).

The procedure shown in FIG. 8 is started by the transition to the chart display screen, and the chart display screen is displayed (S3).
1). The medical information master data is read from the medical information definition master file 304, and the patient consultation history file 3 is read.
05, the medical history of the currently selected patient is read, and the medical information of the currently selected patient is read from the medical information input data file 301 (S33). Next, as shown in FIG. 6, the medical care information is displayed in the medical care information display area (S35).

In step S37, an event is awaited. When the fixed phrase creation button (see FIG. 6) is clicked, it is selected (indicated by a thick line frame in FIG. 6).
If there is a medical information display area (S39: YES),
The sentence type (S4) displayed in the medical information display area
1) Each piece of medical information is not registered in the fixed phrase master file 303 with the same contents of medical information (S43: YE)
S), each is registered in the fixed phrase master file 303 (S45). When the processing in steps S41 to S45 is completed for all the medical information in the medical information display area, the process exits the loop and returns to step S37.

If another event has occurred as a result of the standby at step S37, processing corresponding to the other event is performed (S55). If the end event has occurred (S51: YES), the chart display screen is closed (S53).

Each medical information recorded in the standard sentence master file 303 in the step S19 or S45 is listed as a standard sentence candidate in the standard sentence selection field in the medical information input screen (FIG. 5) for each type of medical information. Is displayed. The medical information selected from this list display is transcribed to the medical information input field selected at that time, and is recorded in the medical information input data file 301 as the medical information of the patient.

Second Example Apparatus: An electronic medical record apparatus according to a second example corresponds to claims 3 to 5. In the electronic medical record apparatus of the second example, the medical care information of the currently selected patient is recorded in the temporary fixed phrase master file 302 for the patient in a text data format. The selection of the patient is performed when the patient is received by the terminal device at the reception desk. Further, when the selection of the patient is canceled after the medical examination or the medical treatment ends, the temporary fixed phrase master file 302 for the patient is deleted. In other words, in the electronic medical record apparatus of the second example, the temporary fixed phrase master file 302 for the patient is created only during the period when the patient to be examined or treated is selected, and when the selection is released, the temporary fixed phrase master file 302 is created. By deleting 302, the display of optimal fixed phrase candidates and the saving of storage area are realized.

When a patient is received by the terminal device at the reception desk, the patient is selected and the procedure of FIG. 9 is started,
The medical information master data is read from the medical information definition master file 304, the medical history of the selected patient is read from the patient medical history file 305, and the medical information of the selected patient is read from the medical information input data file 301 ( S61).

The sentence-type medical information read from the medical information input data file 301 (S63) is conditioned on the condition that the medical information having the same content is not registered in the temporary template master file 302 (S65: YES). Are registered in the temporary fixed phrase master file 302 (S67). Steps S63 to S63 for all medical information read from the medical information input data file 301
When the process of 67 is completed, the process exits the loop and the procedure of FIG. 9 ends. The fixed phrase selection column in FIG. 5 shows a state in which the data of the temporary fixed phrase master file in the upper part of FIG. 4 is reflected.

Each piece of medical information recorded in the text data format in the temporary fixed phrase master file 302 as described above is listed as a fixed phrase candidate in the fixed phrase selection field in the medical information input screen for each type of medical information. Is displayed. After the medical information selected from this list display is transcribed to the medical information input field selected at that time, and is appropriately corrected in the medical information input field (or as it is without being corrected), The medical information of the patient is recorded in the medical information input data file 301.

[0022]

According to the first and second aspects of the present invention, since the medical information selected from the medical information display area and / or the medical information input field is recorded in the standard text file, a normal medical record recording operation is performed. The work is simple because a fixed phrase can be registered in the middle. According to the third to fifth aspects, the sentences in the past medical information of the patient are read out and recorded in the personal fixed-form sentence file for the patient. Can be used.

[Brief description of the drawings]

FIG. 1A is a block diagram illustrating a configuration of an electronic medical record device according to an embodiment, and FIG. 1B is a block diagram illustrating a case where the electronic medical record device has a network configuration.

FIG. 2 is an explanatory view exemplifying a medical information input data table (upper) and a medical information definition master table (lower).

FIG. 3 is an explanatory view exemplifying a patient consultation history table (upper row) and a fixed phrase master table (lower row).

FIG. 4 is an explanatory view exemplifying a temporary template master table (FIG. 4) and a patient master table (lower).

FIG. 5 is an explanatory diagram illustrating a medical care information input screen.

FIG. 6 is an explanatory diagram illustrating a chart display screen.

FIG. 7 is a flowchart showing a procedure for registering fixed phrases on the medical care information input screen.

FIG. 8 is a flowchart showing a procedure for registering fixed phrases on the chart display screen.

FIG. 9 is a flowchart showing a procedure for creating a fixed phrase from the medical information of a selected patient and recording the fixed phrase in a temporary fixed phrase master table.

[Explanation of symbols]

 20 CPU 30 auxiliary storage device

Claims (5)

[Claims] An electronic medical record having a function of transferring medical information selected in a fixed phrase selection field to a medical information input field and a function of recording medical information input from the medical information input field in a medical information data file. A selection unit for selecting medical information in a medical information display area and / or medical information in the medical information input column; and a fixed form sentence for recording the medical information selected by the selecting unit in a fixed form file. An electronic medical record apparatus comprising: a recording unit; and a candidate display unit that displays each medical information recorded in the fixed phrase file as a selection candidate in the fixed phrase selection field. 2. The electronic medical record apparatus according to claim 1, wherein said fixed form sentence recording means performs recording in response to an input from an input means for instructing recording of a fixed form sentence. 3. An electronic medical record having a function of transferring medical information selected in a fixed phrase selection field to a medical information input field and a function of recording medical information input from the medical information input field in a medical information data file. An apparatus, comprising: creating means for creating a personal fixed phrase file for a selected patient; and medical information transfer means for reading past medical information of the patient from the medical information data file and transferring the information to the personal fixed file. An electronic medical record apparatus, comprising: medical information transferred to the personal fixed phrase file, and candidate display means for displaying the medical information as selection candidates in the fixed phrase selection field. 4. The electronic medical record apparatus according to claim 3, further comprising: a deletion unit configured to delete the personal fixed phrase file when the selection of the patient is released. 5. The electronic medical record device according to claim 3, wherein the creating means creates a personal fixed phrase file of the patient when the patient is accepted at the visit window.