JP2004078601A - Assessment file - Google Patents

Abstract

<P>PROBLEM TO BE SOLVED: To provide an assessment file as a medical treatment record format realizing a new data abstracting function by gathering data of recorded contents based on data of medical treatment, standardization for nursing care record items, and quantitative determination of recording methods, which are not included in conventional electronic medical records, nursing care support apparatus or clinical passes. <P>SOLUTION: An assessment sheet 1 is provided with an outcome 3 which is provided for a name of a disease and every progressed day after a medical operation and is all target goals of symptoms and conditions of a disease for a patient given cares for the disease, and an assessment 2 as indexes which become criteria of assessment for achieved rates of all target goals at a progressed date. Further, the assessment file is formed by collecting assessment classes for each disease, which are formed by collecting all the assessment sheet 1 for each disease during all progressed days. Thus, gathering data of the recorded contents is carried out by standardization of record items and quantitative determination of recording methods, and recorded data are integrally shared with medical staffs of all categories including medical doctors. Consequently, nursing care records are evaluated as data having great value of information. <P>COPYRIGHT: (C)2004,JPO

Description

[0001]
TECHNICAL FIELD OF THE INVENTION
The present invention relates to the standardization of medical practice, an assessment file from which a medical or technical knowledge is built into an electronic or non-electronic database.
[0002]
[Prior art]
There are two conventional medical records in hospitals. One is a medical record generally used conventionally, so-called medical record. In the medical record, information obtained by observation of patients by doctors and nurses is recorded as sentences. In recent years, there has been proposed a system called electronic medical records, which replaces the conventional handwritten medical records with text entered on a personal computer and saved as a database, or that can be viewed by other doctors and hospitals. Has been
[0003]
The other is a general clinical path currently under development. The clinical path standardizes and clarifies various goals to be achieved in the course of a series of medical treatments (hereinafter referred to as “outcomes”) for patients who are considered to be in a certain category. is there.
[0004]
Conventional medical records, even when digitized, are simply hand-written information entered by a personal computer using a word processor, and are merely records of subjective observations by doctors and nurses, that is, problem-oriented records. Was. Such an electronic medical record not only requires a great deal of effort when extracting recorded information as data later, but also does not guarantee that necessary data can always be extracted.
[0005]
Further, in the above-mentioned clinical path, there are some indicators (hereinafter, referred to as “assessment”) for determining whether or not the outcome has been achieved in the outcome. Despite some awareness of these relationships, the idea of organizing and listing outcomes and assessments has not been reached.
[0006]
In the past, in the field of clinical medicine, treatment criteria for large disease classifications such as the name of the main disease, for example, gastric cancer and its pathology, for example, the stage of the disease, for example, selection criteria for anticancer drugs or surgery. The research has been done professionally for quite some time. Some have published guidelines. However, there is scientific evidence for more field-level issues, i.e., the judgment and treatment of current symptoms, such as fever and blood pressure fluctuations, and ever-changing symptoms that occur in the practice of these patients. Some data extraction has rarely been performed.
[0007]
Now that the medical economic problem has emerged as a social problem, there is a need for safe and appropriate enforcement of efficient medical care. For that purpose, it is necessary to work to re-evaluate such small problems in clinical practice.
[0008]
On the other hand, a nursing support device capable of feeding back nursing information to the preparation of the next nursing care plan is disclosed in JP-A-8-266483. This is because, in a nursing support device that creates a nursing care plan for a patient based on a doctor's instruction, the doctor's instruction information or doctor order extracted from patient-related information in which the diagnosis result, medical condition, doctor's findings, etc. are recorded. Nursing plan generation means for creating and modifying a nursing plan based on doctor's instruction information input from input means, nursing result information input means for inputting nursing information obtained during nursing work, and information on the nursing information A nursing result information processing means for performing processing, and a display means for displaying information after the nursing result processing after the information processing by the nursing result information processing means. It is configured such that new instruction information can be input from the order input means. In this nursing support device, nursing information such as measurement data of body temperature and blood pressure and nursing findings obtained during nursing work are processed and displayed on display means, and the doctor who sees it gives a new instruction. If entered, the nursing plan will be modified.
[0009]
[Problems to be solved by the invention]
However, the above-mentioned nursing support device is intended to create a problem-oriented nursing plan centered on an instruction (order) issued by a doctor to deal with a new problem that has occurred in a patient. It does not create an outcome-oriented nursing plan based on outcomes set in advance through discussions involving nurses. Therefore, the system is not suitable for standardizing medical records and nursing record items, and quantifying recording methods to convert the contents of records.
[0010]
The present invention provides a new data extraction function by digitizing the record contents by standardizing medical records and nursing record items, and quantifying the record method, which is not in such a conventional electronic medical record or nursing support device or the above-mentioned clinical path. An object of the present invention is to provide an assessment file which is a medical record format that realizes the above.
[0011]
[Means for Solving the Problems]
The first configuration of the present invention is created for each name of a disease and each post-operative day, and is an outcome that is a target of achieving various symptoms and medical conditions for a patient who is treated for the disease; This is an assessment file that is an assessment sheet that includes an assessment sheet, which is an index that serves as a standard for evaluating the degree of achievement of the achievement goal, and that is obtained by gathering assessment classes for each disease for all elapsed days and for each disease. .
[0012]
Here, "symptoms" are barometers of a patient's subjective situation such as pain or lack of appetite, and "morbidity" is an objective situation of body temperature, pulse, blood pressure, etc. It is a barometer.
[0013]
"Outcomes" are the patient's achievement goals set during the course of treatment.
The “assessment” is a combination of observation items and inspection data and states and values considered to be appropriate. A combination of one outcome and a single or a plurality of assessments (see FIG. 3B) related thereto is referred to as an “outcome unit” (see FIG. 3A). Among the management-level outcomes, those that have been standardized beyond the diagnosis name and the date of the date can be used on various assessment sheets with different diagnosis names and the date of the date. Some outcomes are defined by various achievement goals only, and others are set by a combination of tasks (tasks) performed after the achievement of the goals. When the diagnosis name is unknown, it can be a basic unit of various achievement targets set for promoting treatment.
[0014]
The “assessment sheet” is a set of outcomes set for each lapsed day after hospitalization (after surgery) for each designated diagnosis name. It can also be referred to when creating an assessment sheet for a new diagnosis.
An “assessment class” is a set of assessment sheets for one diagnosis. It can also be referred to when creating an assessment class for a new diagnosis name.
An “assessment file” is a set of defined assessment classes, and is a medical expertise database.
[0015]
This assessment file breaks down the problem-solving thinking process performed in daily medical practice into outcomes and assessments, and collects and summarizes the information for each disease and treatment method to be treated. The purpose of this study is to clarify the universal laws of the human body beyond diseases by extracting combinations of various goals and their indicators from past treatment results for various diseases and organizing them across diseases. As a result, an assessment file as a medical expertise database is constructed. The outcome may describe a medical practice (task) performed when the outcome is achieved.
[0016]
According to a second aspect of the present invention, the outcome in the assessment sheet is based on past treatment results as various goals to be achieved by a patient in a series of medical treatments from the start of treatment for the disease to the date of discharge from the hospital. The first configuration, wherein the assessment is based on past results of patient observation items and test data at the elapsed date as to whether or not the outcome has been achieved. Is an assessment file.
[0017]
Many medical professionals routinely work to find universal criteria by decomposing symptoms and pathological conditions to some extent (partialization), even if they are not conscious. The criteria for each of these components, which each clinician has, can be standardized by averaging through discussions or optimizing based on scientific evidence. In particular, hospitals with staff of specialized doctors and medical technicians, and hospitals that provide advanced treatment, visit patients who are referred to from other hospitals and have a certain name of the disease for medical treatment and treatment. I do. Then, the medical record of the name of the disease is also accumulated, so that successful cases and medical problems of our hospital can be understood. Many evaluation criteria are created from such treatment results and standardized.
[0018]
One medical plan can be created by combining the standardized parts in advance in this way. This is consistent with the aim of the clinical path currently being tested. An assessment file that collects these parts becomes a database of medical expertise and can be basic data for computerization.
[0019]
BEST MODE FOR CARRYING OUT THE INVENTION
An embodiment of the present invention will be described below with reference to FIGS.
The assessment file is actually created in the process of creating a daily pass, which is a daily medical record for a patient, disclosed in the specification of Japanese Patent Application No. 2001-309075.
[0020]
One of the major features of the rolling pass is that it specifies a relatively fine (daily and concrete) level of outcome from various viewpoints as a treatment goal for the day.
[0021]
As a specific example of the outcome, FIG. 1 shows the outcome on the first day after laparoscopic cholecystectomy. The outcome states the following:
・ The breathing state is stable.
・ Circulation dynamics are stable.
・ I can get out of bed.
・ Can control pain.
・ Can control pain other than pain.
・ There is no problem with the wound.
・ Drain removal.
・ Not complaining of abnormal abdominal pain (unexpected complications)
・ Intestinal paralysis improves.
・ Meals can be started.
[0022]
Furthermore, assessments for evaluating these outcomes are listed in the daily pass shown in FIG. 2 in advance. That is, the outcome to be satisfied by the patient on that day and the assessment items to be observed and evaluated by the medical technician on that day are ideally described in a state that corresponds to a wasteful and swift manner.
[0023]
Of course, as an observation item that does not correspond to the outcome, the concept of a screening item (an observation item for checking whether something unexpected has occurred) is also adopted.
[0024]
In addition, since normal values of inspection data are determined for all of these observation items, extremely simple entry is possible when recording the results.
[0025]
FIG. 3 shows an assessment sheet one day after laparoscopic cholecystectomy. The assessment sheet 1 is provided with a column 2 for describing a disease name and an elapsed date after the operation, a column 3 for describing an outcome, a column 4 for describing an assessment, and a column 5 for describing a classification.
[0026]
The contents of Outcome column 3 are common from the first postoperative day to the date of discharge for one disease name, but the contents of Assessment column 4 differ as the postoperative day progresses . In the outcome description column 3, in addition to the outcome, a medical practice (task) to be performed when the assessment is achieved is also described. The classification described in the classification description column 5 is such that it is easy to search for an outcome when selecting an outcome from an assessment file which is a collection of assessment sheets.
[0027]
FIG. 4 shows a summary of the daily pass, focusing only on the relationship between the outcome and the observation item. FIG. 5 shows a schematic diagram of the assessment file.
[0028]
When the outcomes to be set are subdivided to this level (daily and concrete level), each of these outcomes has “universality”.
[0029]
In other words, even for patients with different types of diseases or surgery, it is possible to use almost the same outcome for similar times and situations, and the difference is not the outcome itself, but “ This is a combination of outcomes (see FIG. 5).
[0030]
Therefore, the relationship between the outcome and the observation item is made into a data base so that the observation item can be extracted from the outcome whenever desired.
[0031]
It is also possible to extend the concept of an assessment file and incorporate test results corresponding to outcomes as well as observation results corresponding to outcomes.
Then, after a certain amount of accumulation, the assessment file 6 becomes a knowledge data bank of medical expertise as shown in FIG.
[0032]
It should be noted here that the assessment file 6 is not a database in which individual patient information is collected, but a database of medical expertise that is originally in the brain of a medical practitioner.
[0033]
The assessment file 6 standardizes and accumulates the relationship between the patient observation items corresponding to the outcomes and the test data, and thereby accumulates the data. Becomes the central part when fusing.
[0034]
【The invention's effect】
As described above, the present invention has the following effects.
[0035]
(1) The assessment file of the present invention provides a standardized medical treatment plan for a certain category of patients. That is, since the medical technician prepares the items to be observed for the patient in a predetermined format (a tear-off clinical pass), those items are recorded as data, and the risk of missing the record is extremely low. In addition, since the database is a detailed database for providing a standardized medical treatment method, it can be used for medical education by referring to the database.
[0036]
(2) Since the assessment file of the present invention is of an outcome-oriented type rather than a problem-oriented type as in conventional medical charts and nursing support devices, it is possible to standardize the outcomes and assessments, and to record the nursing records recorded accordingly. Can also be standardized. In other words, record items are standardized, and the contents of records are converted into data by quantifying the record method. As a result, records can be shared with medical staff of all occupations including doctors, and nursing records have high information value as data. Can be obtained.
[0037]
(3) By enriching the outcomes and assessment items, there is no omission in observation items and medical practices, there is no need to input sentences like an electronic medical record, and it is sufficient to describe the degree of achievement, so recording time is also long Shorten.
[0038]
(4) Outcomes and assessments often apply not only to specific diseases, but also to other diseases, so by changing the combination of multiple outcomes, it is possible to apply those that have few cases and are not patterned. , Increase flexibility.
[0039]
(5) The assessment file is a methodology for collecting and classifying medical expertise, and is used to accumulate and combine achievement targets and indices from past treatment results. This makes the assessment file a knowledge databank of medical expertise.
[0040]
(6) It is easy to construct a database, which leads to modernization and advancement of medical care, such as disclosure of information to the general public, patients and other hospitals, and unification and standardization of medical care.
[Brief description of the drawings]
FIG. 1 is an explanatory diagram showing an example of an outcome item.
FIG. 2 is an explanatory diagram showing a description example of a tear-off path;
FIG. 3 is a front view of an assessment sheet showing the embodiment of the present invention.
FIG. 4 is an explanatory diagram summarizing the relationship between outcomes and observation items in an assessment sheet.
FIG. 5 is an explanatory diagram showing the relationship between assessment sheets and outcomes for different diseases.
FIG. 6 is an explanatory diagram showing a state in which an assessment file is made into a database.
[Explanation of symbols]
1 Assessment sheet 2 Disease name and post-operative date entry field 3 Outcome entry field 4 Assessment entry field 5 Classification entry field 6 Assessment file

Claims (2)

An outcome that is created for each disease name and post-operative day, and is an achievement target of various symptoms and conditions for a patient who is treated with the disease, and a standard for evaluating the degree of achievement of the achievement target at the elapsed date. An assessment file in which an assessment sheet in which assessments, which are indices as indexes, are described is set for each disease, and an assessment class in which an assessment sheet is collected for each disease for all elapsed days. Outcomes in the assessment sheet are collected from the past treatment results as various goals to be achieved by the patient in a series of medical treatments from the start of treatment for the disease to the date of discharge from the hospital, 2. The assessment according to claim 1, wherein the assessment is based on past results of patient observation items and test data and their appropriate values on the day of the elapsed time for determining whether the outcome has been achieved. File.

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