JP2005038262A - Electronic medical chart/ordering integrated control method, electronic medical chart/ordering integrated control program, and storage medium - Google Patents

Abstract

<P>PROBLEM TO BE SOLVED: To make a doctor complete a medical examination action without causing an interruption of his/her intellectual process and to reflect a medical examination policy differed for every doctor to ordering by integrating an electronic medical chart to ordering. <P>SOLUTION: An electronic medical chart creation processing part 213 extracts a symptom keyword matched to a preliminarily registered symptom keyword from an examination finding inputted to an electronic medical chart creation area by a keyword extraction processing part 214, and displays it in a keyword list display area. An doctor-based order history display processing part 215 reads the order history issued in the past by the doctor to the symptom keyword designated from the keyword list from a database, and displays it in a doctor-based order history display area. An order list creation processing part 216 transfers an item selected from the order history to an order list creating area, issues an order, when the order list is completed, to each section, and accumulates it as a new doctor-based order history. <P>COPYRIGHT: (C)2005,JPO&NCIPI

Description

  The present invention relates to an electronic medical record / ordering integrated control method and a program therefor, in which electronic medical record input and ordering can be performed by a series of input processes on an electronic medical record created in a medical activity at a medical institution or the like. The present invention relates to a recording medium that records

  Conventionally, as an electronic medical record system, a patient information display part such as a name on a display screen, an electronic medical chart display part for displaying medical chart information, a guidance fee implementation information display part for the patient, and a shortcut as a medical information search means Display the display part and use the shortcut function of the shortcut display part to display electronic medical record information according to the conditions applicable to the patient, such as a prescription set for influenza or a prescription set for liver function, etc. A screen display has been proposed (for example, see Patent Document 1).

  For example, when a doctor inputs an instruction for X-plug inspection from the terminal device in the examination room, the instruction is transmitted to the terminal device in the X-plug inspection room, or when a prescription instruction for a medicine is input, the prescription instruction is transmitted to the terminal device in the dispensing room. An ordering system is also known (see, for example, Patent Document 2).

JP 2003-122849 A JP 2002-189802 A

  By the way, the electronic medical record system and the ordering system are conventionally developed and operated as separate systems independent of each other. That is, the doctor examines the patient in the examination room and inputs the electronic medical record (input of the medical examination findings) by the electronic medical record system. When the medical record is completed, the electronic medical record system is ended, and the ordering system is replaced instead. An operation of starting up, calling up an ordering screen, and inputting various orders (instructions) is performed.

  However, from the viewpoint of doctor's medical practice, the act of examining a patient and inputting findings (input to an electronic medical record) and the instruction based on the findings (input of orders) are the doctor's continuous thought process In spite of the above, the doctor's thought process as a result of the time interruption between the input to the electronic medical record and the input of the order and the visual interruption due to the switching of the display screen. May be inconvenient because it will be interrupted.

  In addition, the above-mentioned order input has a wide range of prescription orders, injection orders, examination orders, treatment orders, surgical orders, etc. for drugs, so various screen switching is performed in order for each order item. It is necessary to input for each order item. For this reason, order entry methods such as inputting order items that can be immediately judged in the middle of finding input to the electronic medical record, or entering each order item while comparing with the findings that have been entered. It is also a factor that further amplifies the inconvenience of interruption of the above thinking process.

  On the other hand, even if the findings are the same, there are many cases in which the contents ordered for each order item are often different for each doctor. For example, even if the findings are respiratory tract inflammation, the drugs prescribed for the findings vary depending on the individual physician's mindset, whether or not certain injections are made, and which injections are taken . This depends on whether the doctor in charge of the examination has deep or shallow experience. Even if the findings are the same, there are cases where different orders (for example, prescription of drugs) should be made for each patient due to differences in constitution or the presence or absence of other medical conditions. For this reason, even if it is possible to search for general order items such as a prescription set for a specific finding, it will not be possible to conduct appropriate medical treatment due to uniform medical treatment, and it will be based on different ideas for each doctor. In addition, there is a disadvantage that additional correction work is required for each order item.

  The present invention has been made in view of such circumstances, and an object of the present invention is to integrate a medical record and an ordering so that a series of medical treatments can be performed without interrupting a doctor's thought process. The object is to provide an electronic medical record ordering integrated control method capable of completing an action. In addition, it is an object of the present invention to provide ordering support adapted to each individual doctor in such an integration.

  In order to achieve the above object, in the first invention related to the electronic medical record ordering integrated control method, the doctor identification information for identifying the doctor who inputs the medical examination findings and the patient identification information for identifying the patient together with the input setting for the patient diagnosis Based on the first procedure for receiving the input of the findings and displaying the examination findings on the electronic medical record preparation area on the display screen of the display means, and the input information to the electronic medical record preparation area, it is stored in advance in the symptom keyword database. A second procedure for extracting a symptom keyword that matches the symptom keyword and displaying it in the keyword list display area on the display screen, and a symptom keyword listed in the keyword list display area in response to an input of a selection command Corresponds to the doctor identification information based on the symptom keyword selected from the list and the above doctor identification information A third procedure for reading out order history information ordered in the past for a symptom corresponding to the selected symptom keyword from a doctor-specific order history database and displaying it in the doctor-specific order history display area of the display screen; And a fourth procedure for transcribing individual order items selected from the order history information displayed in the doctor-specific order history display area to the order list creation area on the display screen in response to an input of a selection command. (Claim 1).

  In the case of the present invention, diagnosis findings are input to the electronic medical record creation area by the first procedure, and the electronic medical record is created, and the symptom keyword is extracted by the second procedure in parallel with or after the creation. Symptom keywords included in the examination findings are listed up in the keyword list display area. When the doctor inputs an instruction to select one of the symptom keywords displayed in this keyword list display area (for example, clicks with the mouse), the order items that he ordered in the past for the symptom of the same symptom keyword in the third procedure are displayed. It will be displayed in the order history display area for each doctor. Then, with reference to the order item displayed in this doctor-specific order history display area, the patient's examination findings are compared, and if the displayed order item is acceptable, a selection command is input for the order item (for example, a mouse) Click), the order item is directly transferred to the order list creation area for the current patient. Thereafter, by repeating the input of this order item selection command or adding a new order item, the current order list is completed in the above order list display area. Will be completed. As described above, from the input of the doctor's examination findings (creation of the electronic medical record) to the creation of the order list (ordering) for the patient can be performed based on a series of thoughts. Therefore, it is possible to easily secure the action from the examination to the treatment that sufficiently reflects the idea of the different order policy. Note that the symptom keyword database used in this control method can be easily created and updated by using, for example, disease name index master data issued by the Ministry of Health, Labor and Welfare.

  In the present invention, the following various specific items can be additionally employed. That is, first, the keyword list display area and the order list creation area are switched to each other in the same display area on the display screen. By doing so, the number of divisions of the display screen area of the display means can be further reduced, and accordingly, the individual display areas and creation areas can be widened for easier viewing.

  Second, in response to the input of the past medical record reference command, the past medical examination information of the specific patient corresponding to the patient identification information is read from the electronic medical record database and displayed in the past medical chart reference display area on the display screen. 5 is further provided (claim 3). In this way, it is possible to examine the current patient's condition while referring to the symptoms, etc. of the previous examination, especially when inputting the examination findings in the first procedure. You will be able to perform medical care. In this case, the past chart reference display area and the doctor-specific order history display area may be switched to each other in the same display area on the display screen. In this case, since the doctor-specific order history display area is not particularly necessary when inputting the medical examination findings in the first procedure, the area on the display screen is effectively used as the past chart reference display area. Similarly to the above, the number of divisions of the display screen area can be reduced to make it easier to see.

  Thirdly, a sixth procedure for learning and recording the current order list displayed and created in the order list creation area in response to the input of the order issuance command in the physician order history database is provided. In this way, in addition to ordering based on the order issue command, the order history information for each doctor in the order history database for each doctor is updated to newer information, and the order history information is enhanced. It becomes possible to reflect the way of thinking for newer orders for each doctor.

  On the other hand, in the second invention relating to the electronic medical record ordering integrated control program, at least one unit comprising an input unit and a display unit and connected to a database unit including a doctor-specific order history database and a symptom keyword database so as to communicate with each other. The above-mentioned display is executed by the doctor terminal device, and the doctor terminal device receives the input of the doctor findings together with the doctor identification information for identifying the doctor who inputs the doctor findings and the patient identification information for identifying the patient. A symptom keyword that matches a symptom keyword stored in advance from the first function of displaying the examination findings in the electronic medical record creation area on the display screen of the means and the examination findings information received by the electronic medical record creation means Extract and display in the keyword list display area on the display screen The specific doctor corresponding to the doctor identification information based on the second function and the symptom keyword selected from the symptom keyword list listed in the keyword list display area in response to the input of the selection command and the doctor identification information A third function for selecting, in the past, order history information ordered for the symptom corresponding to the selected symptom keyword from the doctor-specific order history database and displaying it in the doctor-specific order history display area of the display screen; An electronic system for realizing a fourth function of transferring the order contents selected from the order history information displayed in the doctor-specific order history display area to the order list creation area on the display screen in response to an instruction input The medical record ordering integrated control program is defined (claim 6).

  In the case of the second aspect of the invention, the electronic medical record ordering integrated control program according to claim 1 is installed by installing the electronic medical record ordering integrated control program in the doctor terminal device and causing the functions to be executed. It will surely be realized.

  In addition, in response to the above-mentioned invention, the past medical examination reference information corresponding to the patient identification information is read from the electronic medical record database in response to the input of the past medical chart reference command, and is referred to the past medical chart reference display area on the display screen. By further providing the fifth function to be displayed (Claim 7), the electronic medical record ordering integrated control method according to Claim 3 can be reliably realized. Alternatively, the present invention may further include a sixth function for learning and recording the current order list displayed and created in the order list creation area in response to the input of an order issuance command in the doctor-specific order history database. (Claim 8), the electronic medical record ordering integrated control method according to claim 5 can be reliably realized.

  Of the first to sixth functions, a part of any one of the functions is realized by another program that operates on a computer system that is a doctor's terminal device. An instruction for calling a function realized by the other program may be included in the integrated control program. In addition, each electronic medical record ordering integrated control program described above is installed on a server connected to be able to communicate with these doctor terminal devices without being installed on each doctor terminal device. Thus, each doctor's terminal device may be operated by each electronic medical chart ordering integrated control program on the server side.

  Furthermore, in the third invention relating to the computer-readable recording medium, the electronic medical record ordering integrated control program according to any one of claims 6 to 8 is recorded (claim 9).

  As described above, according to the electronic medical record ordering integrated control method of any one of claims 1 to 5, from the input information by creating the electronic medical record by inputting the examination findings to the electronic medical record creating area Symptom keywords are extracted and displayed in the keyword list display area. If a doctor selects and inputs an arbitrary symptom keyword, the order items that he ordered in the past in the case of the symptom of the same symptom keyword are classified by doctor. It will be displayed in the order history display area. For this reason, refer to the order items displayed in this doctor's order history display area, compare with the current patient's examination findings, and if an appropriate order item is selected and entered, the order item will be the order list for the current patient. The current order list can be completed by being transferred to the creation area as it is. As described above, the entire medical practice from the creation (diagnosis) of this electronic medical record for a patient to the ordering (coping) for the patient can be performed based on a series of thoughts in front of the patient. In addition, even if the symptoms are the same, it is possible to easily secure a medical practice that sufficiently reflects the concept of a different order policy for each doctor.

  In particular, according to claim 2, since the keyword list display area and the order list creation area can be switched to each other in the same display area on the display screen, the number of divisions of the display screen area of the display means can be reduced. Accordingly, it is possible to widen the individual display area and the creation area for easier viewing.

  According to the third aspect of the present invention, the past medical examination reference information about the current patient can be referred to and displayed in the past medical chart reference display area by inputting the past medical chart reference command. The patient's current situation can be examined while referring to the symptoms and the like at the time of the examination, and medical treatment continued from the past examination can be performed. In this case, according to the fourth aspect, the past chart reference display area and the doctor-specific order history display area can be switched to each other in the same display area on the display screen. Instead of the doctor-specific order history display area which is not necessary, it can be effectively used as a past chart reference display area.

  According to the fifth aspect, in addition to ordering based on the order issuance command, the order history information for each doctor in the order history database for each doctor can be updated with newer information to enhance the order history information. It is possible to reflect the new order policy concept for each doctor.

  On the other hand, according to the electronic medical record ordering integrated control program of any one of claims 6 to 8, the electronic medical record ordering integrated control method can be reliably realized. That is, according to claim 6, the electronic medical record ordering integrated control method according to claim 1, according to claim 7, the electronic medical record ordering integrated control method according to claim 3, according to claim 8, The electronic medical record ordering integrated control method according to claim 5 can be realized.

  According to the computer-readable recording medium of claim 9, it is possible to provide a recording medium of the electronic medical record ordering integrated control program according to any one of claims 6 to 8, which is provided to a doctor. By installing in the terminal device for use, etc., the above-described functions can be executed to obtain the effect of the electronic medical record ordering integrated control method.

  Hereinafter, embodiments of the present invention will be described with reference to the drawings.

  FIG. 1 shows an electronic medical record ordering integrated control system installed in a hospital for carrying out an embodiment of the present invention. In the same figure, 2, 2 and 2 are doctor terminal devices, 3 is database means, 4 is a group of terminal devices for departments that receive the order and play a role along the order, and each doctor terminal device 2 is The database means 3 and each terminal unit group 4 are connected to each other via a router 5 or the like so as to be communicable (for example, LAN connection). 1 shows three doctor terminal devices 2, 2,... For three doctors assuming a relatively small hospital or clinic. The number may be increased or decreased according to the scale of the hospital, and at least one is sufficient.

  Each of the doctor terminal devices 2 includes a device main body 21 composed of a personal computer (hereinafter simply referred to as “personal computer”) having a CPU, RAM, ROM, HDD and the like, and input means 22 such as a keyboard 22a and a mouse 22b. And display means 23 constituted by a monitor such as a CRT or TFT. For example, a combination of a TFT pen tablet and a stylus pen having both functions may be used as the input unit and the display unit. Further, a scanner, an image input driver, or the like may be connected to the apparatus main body 21 as input means, and a printer or the like as output means may be connected.

  The apparatus main body 21 is in a state in which an OS pre-stored in the HDD, other general-purpose applications, and various driver software are stored in advance and can function, as shown in FIG. A past medical chart reference processing unit 212, an electronic medical record creation processing unit 213, a keyword extraction processing unit 214, a doctor-specific order history display processing unit 215, an order list creation processing unit 216, and an order history storage processing unit 217 are provided. In addition, a switching processing unit, a search processing unit, a sample display processing unit, etc. (not shown) are provided. Most of the functions of these processing units 211 to 217 are executed by an electronic medical record ordering integrated control program installed in advance by a recording medium such as a CD-ROM.

  The database means 3 includes a symptom keyword database 31, an electronic medical record database 32, and a doctor-specific order history database 33. In the symptom keyword database 31, disease name index master data of the Ministry of Health, Labor and Welfare is registered in advance, and terms indicating symptoms such as disease names are accumulated. The electronic medical record database 32 stores and stores the electronic medical records created by each doctor's terminal device 2, and the electronic medical records from the past to the present are stored for each patient. The doctor-specific order history database 33 stores and accumulates the order history ordered by each doctor. The order history from the past to the present is related to the symptom keyword when the order is ordered, and is classified by the ordering doctor. Accumulated.

  Each department terminal device group 4 includes an accounting terminal 41, a pharmacy terminal 42, a radiology terminal 43, an examination room terminal 44, a treatment room terminal 45, and the like. Each of these terminals 41 to 45 is composed of a personal computer provided with the input means and display means described above, receives and displays the order matters sent and issued by each doctor's terminal device 2, Each department deals with each patient based on the displayed order items.

  Hereafter, each process by each process part 211-217 of the said apparatus main body 21 is demonstrated, referring the display screen example of the display means 23 shown in FIG.3 and FIG.4. First, when the electronic medical record ordering integrated control program is started and doctor identification information for specifying a doctor to be input and patient identification information for specifying a patient are input, a display screen 24 as illustrated in FIG. 3 is displayed. Reference numeral 241 denotes an electronic medical record creation area, 242 denotes a keyword list display area, and 243 denotes a past medical chart reference display area. The keyword list display area 242 shares the same area as the order list creation area 244 as shown in FIG. 4, and the past medical chart reference display area 243 shares the same area as the doctor-specific order history display area 245, respectively. The display is switched as will be described later.

  In the lower part of the electronic medical record creation area 241, a delete button 2411 for executing a full-sentence deletion function, a text-cutting button 2412 for executing a deletion function for each sentence unit, and a deletion function of a handwritten input diagram A drawing button 2413 for executing the function and a rubber button 2414 for executing a function of deleting an arbitrary part are arranged. The doctor-specific order history display area 245 is further divided into areas according to order types and disease names, and the order items corresponding to each order type are displayed. For example, the prescription column 2451, the injection column 2452, the examination column 2453, the radiation column 2454, the treatment column 2455, the surgery column 2456, the disease name column 2457, the modifier column 2458 for the disease name, and the disease name index master column 2459 as the order item areas It is divided into

  Various command buttons are arranged in the upper area of the display screen 24. Reference numeral 251 is a chart reference button, 252 is a key list switching button, 253 is an order list switching button, 254 is an order issue button, 255 is a record sample display button, 256 is a character search button, and 257 is a keyword search button. When these buttons are placed on the cursor and the mouse 2b is clicked, each command is input and the function of each button is realized.

  When the medical chart reference button 251 is clicked, a past medical chart reference command is input, and in response to this, the past medical chart reference processing unit 212 reads out the past medical chart corresponding to the patient identification information from the electronic medical record database 32, while the order history by doctor is always used. The area set in the display area 245 (default setting) is switched to the past chart reference display area 243, and the read past chart is displayed in the past chart reference display area 243.

  When the order list switching button 253 is clicked, a switching command is input. Upon receiving this switching command, the switching processing unit switches the area closer to the center of the display screen 24 from the keyword list display area 242 to the order list creation area 244. It has become. When the key list switching button 252 is further clicked, a switching command is input. Upon receiving this switching command, the switching processing unit changes the area near the center of the display screen 24 from the order list creation area 244 to the keyword list display area 242. Can be switched again.

  When the order issuance button 254 is clicked, an order issuance command is input, and in response to this, the communication processing unit 211 changes the order items for each order type created in the order list creation area 244 to the order of the terminal device group 4 for each department. It transmits to the terminals 41 to 45 of each department corresponding to the event.

  As a specific example, FIG. 5 shows the one corresponding to FIG. 3, and FIG. 6 shows the past chart reference display area 243 of FIG. 3 switched to the doctor-specific order history display area 245. In FIG. 5, for the electronic medical record creation area 241, the SOAP system S (Subjective; subjective data that the patient directly appeals), O (Objective; (Objective data taken by doctors and nurses), A (Assessment), and P (Plan; plan for diagnosis, treatment, inspection, etc.) are entered and displayed with one blank line. An example is shown. The symptom keyword that matches the symptom keyword registered in the symptom keyword database 31 is extracted from the input information (input items) to the electronic medical record creation area 241, and the extracted symptom keyword is displayed in the keyword list display area 242. It is displayed. In addition, when the extracted symptom keyword is displayed in the keyword list display area 242, the symptom keyword that the doctor has ordered in the past is highlighted among the extracted symptom keywords based on the doctor identification information. It is like that. In the example of FIG. 5, the symptom keywords “diarrhea”, “head”, “headache”, and “fever” are highlighted. On the other hand, in the past medical record reference display area 243, the past medical record of the patient is read from the electronic medical record database 32 and displayed based on the patient identification information input first. This past medical record is displayed by being classified according to the above-mentioned Subjective, Objective, Assessment, and Plan when the previous electronic medical record is created.

  Further, in FIG. 6, as an example in the case where “diarrhea” highlighted in the symptom keyword displayed in the keyword list display area 242 is selected (for example, by placing the cursor and clicking with the mouse 22 b), In the order history display area 245, the order history that the specific doctor specified by the doctor identification information has ordered in the past with the symptom keyword “diarrhea” is read from the order history database 33 for each doctor and displayed. Yes. Then, the above “diarrhea” is displayed in the display column next to the key search button 257, indicating that “diarrhea” has been selected as a symptom keyword.

  Next, the flow from the creation of the electronic medical record to the ordering system by the processing units 211 to 217 of the apparatus main body 21 configured by the electronic medical record / ordering system integrated control program will be described with reference to the flowchart of FIG. First, as described above, input of doctor identification information and patient identification information is accepted as a precondition, and the display screen 24 shown in FIG. 3 is displayed. Next, it is determined whether or not a past medical record reference command has been input (step S1). If there is an input by clicking the medical chart reference button 251, the past medical chart reference processing unit 212 determines the current patient's information based on the patient identification information. The past medical record is read from the electronic medical record database 32 and displayed in the past medical record reference display area 243 (YES in step S1, step S2; see FIG. 5). If there is no input, step S2 is skipped and the electronic medical record creation processing unit 213 The medical examination input from the doctor is accepted and the information is displayed in the electronic medical record creation area 241 (NO in step S1, step S3). In parallel with or after the input of the examination findings, symptom keywords matching the symptom keywords registered in the symptom keyword database 31 are extracted from the input items input to the electronic medical record creation area 241 by the keyword extraction processing unit 214, All the extracted symptom keywords are listed up and displayed in the keyword list display area 242 (steps S4 and S5). At this time, based on the doctor identification information, the specific doctor highlights the same symptom keyword as the symptom with the order history in the past from the accumulated data of the doctor-specific order history database 33, and the selection guide described later for the specific doctor. Provide and support.

  Then, it waits for the specific doctor to input a selection command for selecting one of the symptom keywords from among the plurality of symptom keywords listed in the keyword list display area 242 (NO in step S6). If there is an input of a selection command by clicking on the symptom keyword (YES in step S6), the order history that the specific doctor has ordered in the past for the selected specific symptom keyword is searched from the order history database 33 for each doctor. The past order history is read and displayed in the doctor-specific order history display area 245 (step S7; see FIG. 6). At this time, even if the area on the left side of the display screen 24 is the past chart reference display area 243 in the previous stage (step S2), switching is performed to return the area to the doctor-specific order history display area 245. After that, the order history by doctor is displayed. By referring the order history information displayed in the order history display area 245 for each doctor to the specific doctor, what kind of order matters the user has ordered in the past with respect to the symptom of the symptom keyword selected in step S6. It is possible to easily and surely grasp whether or not

  When the specific doctor clicks the order list button 252 to input an order list creation command (YES in step S8), the symptom keyword display in the keyword list display area 242 is switched to the order list creation area 244. Then, the order item (order item) selected from the order items for each order item in the doctor-specific order history display region 245 (clicking on the order item) is transferred to the order list creation region 244 (step S9). The processes from step S5 to step S9 are repeated until the specific doctor completes the order list for the current patient (NO in step S10, steps S5 to S9). That is, after the doctor-specific order history information for the specific symptom keyword selected and designated in step S6 is transferred to the order list, the key list button 252 is clicked to change the order list creation area 244 display to the keyword list display area 242 display. Switching, selecting and specifying another symptom keyword, displaying the order history by doctor for the symptom keyword, clicking the order list button 253, and then order items to be ordered this time from the order history information by doctor, order list creation region 244 Repeat the operation of posting to.

  In addition, if it is desired to add an order item other than the order history information for each doctor, if the specific doctor recognizes it, it can be directly input into the order list creation area 244, or a new order item that is not recognized (for example, In order to add a new medicine), for example, a new order item may be added using the search function of the character search button 256. This search function is performed by inputting, for example, one character of the first letter of the medicine or two characters added to the second character in the character search field next to the character search button 256 and clicking the character search button 256. For example, a list of order items that match this is displayed using the doctor-specific order history display area 245, and if selected and designated, the list is transferred to the order list in the order list creation area 244.

  When the order list is completed, the medical treatment by the specific doctor for this patient is completed. Therefore, if the specific doctor clicks the order issue button 254 and inputs an order issue command (YES in step S10), the next Processing is executed. That is, the current electronic medical record (input information to the electronic medical record creation area 241) is stored in the electronic medical record database 32 together with time information such as patient identification information, doctor identification information, year / month / day / hour / minute / second, etc. In addition, the contents of the completed new order list are accumulated in the doctor-specific order history database 33 in association with the doctor identification information and the symptom keyword included in the current examination finding (step S11). If the same doctor adopts an order item different from the past order history for the same symptom keyword at the time of this accumulation, it will learn and update this new content, What is necessary is just to accumulate the past thing in the state set to 1 rank and ranked. Then, the order items of the order list are transmitted (issued) by the communication processing unit 211 to the terminals 41 to 45 of the departments corresponding to the order type for each order type, and the process ends (step S12). That is, if the order item is “prescription”, the order item (drug order) is transmitted to the pharmacy terminal 42, and if the order item is “injection”, the order item is transmitted to the treatment terminal 45. is there.

  In the above case, the creation of an electronic medical record (input of examination findings) and ordering (instruction) can be executed on the same display screen 24 by a series of continuous operations that greatly shorten the procedure. For this reason, it is possible to continuously process from the input of the diagnosis findings of the doctor who examines the patient to the input of the treatment / judgment to the doctor in a series of thought processes. In addition, to realize the medical treatment (action from examination to instruction) that fully reflects the fact that the medical policy is different for each doctor, that is, the fact that the policy of the order is different for each doctor even for the same symptoms be able to.

  For example, the order history information for each doctor to be referred to and displayed in the above step S7 is based on which medicine is prescribed from various medicines for a certain symptom, what kind of examination is performed, and what kind of treatment is performed. This is a reflection of the doctor's unique policy or way of thinking, making it possible to refer to this information and making it possible to create the current order list from this information (steps S8 to S10). In addition, it is troublesome to find an order item that matches your policy from the general list of general order items, or to correct a set of standard order items individually to match your policy in advance. It can be avoided. In addition, it is possible to easily and quickly achieve not only the ease and speed of the process up to the determination of the order item but also the implementation of different medical treatment policies for each doctor.

  It is possible to support a medical practice from medical examination to treatment in a medical field from a tool used by a doctor or a technical aspect of the tool.

It is a schematic diagram which shows the electronic medical chart ordering integrated control system which implements embodiment of this invention. It is a schematic diagram of the terminal device for doctors. It is a front view which shows the example of a display screen of a display means. It is a front view which shows the example of a display screen different from FIG. FIG. 4 is a specific front view of a display screen corresponding to FIG. 3. It is the specific front view of the display screen which switched a part of FIG. It is a flowchart of electronic medical record ordering integrated control.

Explanation of symbols

2 Doctor's terminal device 3 Database means 22 Input means 23 Display means 24 Display screen 31 Symptom keyword database 32 Electronic medical record database 33 Doctor-specific order history database 241 Electronic medical record creation area 242 Keyword list display area 243 Past medical chart reference display area 244 Order list Creation area 245 Order history display area by doctor

Claims (9)

In response to the input of the doctor identification information for identifying the doctor who inputs the diagnosis findings and the patient identification information for identifying the patient, the diagnosis findings for the patient are received and the diagnosis findings are displayed on the electronic medical record preparation area on the display screen of the display means. A first procedure to display;
A second procedure for extracting a symptom keyword that matches a symptom keyword stored in advance in a symptom keyword database from the input information to the electronic medical record creation area, and listing it in the keyword list display area on the display screen;
The symptom keyword selected from the symptom keyword list selected from the symptom keyword list listed in the keyword list display area in response to the input of the selection command and the specific doctor corresponding to the doctor identification information based on the doctor identification information is selected. A third procedure for reading out order history information ordered in the past for the symptom corresponding to the above from the order history database by doctor and displaying it in the order history display area by doctor on the display screen;
A fourth procedure for transcribing individual order items selected from the order history information displayed in the doctor-specific order history display area to the order list creation area on the display screen in response to an input of a selection command; Electronic medical record ordering integrated control method. The electronic medical record ordering integrated control method according to claim 1,
An electronic medical record ordering integrated control method, wherein the keyword list display area and the order list creation area are switched to each other in the same display area on the display screen. The electronic medical record ordering integrated control method according to claim 1,
A fifth procedure for receiving past medical record reference commands and reading past medical examination information of a specific patient corresponding to the patient identification information from the electronic medical record database and displaying it in the past medical chart reference display area on the display screen; An electronic medical record ordering integrated control method further provided. An electronic medical record ordering integrated control method according to claim 3,
An electronic medical record / ordering integrated control method, wherein the past medical chart reference display area and the doctor-specific order history display area are switched to each other in the same display area on the display screen. The electronic medical record ordering integrated control method according to claim 1,
An electronic medical record ordering integrated control method, further comprising a sixth procedure of learning and recording the current order list displayed and created in the order list creation area in response to an input of an order issuance command in a doctor-specific order history database. It is executed by at least one doctor terminal device that includes an input means and a display means and is connected to a database means including a doctor-specific order history database and a symptom keyword database.
In response to the setting of the doctor identification information for identifying the doctor who inputs the diagnosis findings and the patient identification information for identifying the patient, the diagnosis findings for the electronic medical record preparation area on the display screen of the display means upon receiving the input of the diagnosis findings for the patient A first function for displaying
A second function of extracting a symptom keyword that matches a symptom keyword stored in advance from the examination finding information received and received by the electronic medical record creation means, and listing it in the keyword list display area on the display screen;
The symptom keyword selected from the symptom keyword list selected from the symptom keyword list listed in the keyword list display area in response to the input of the selection command and the specific doctor corresponding to the doctor identification information based on the doctor identification information is selected. A third function of reading order history information ordered in the past for the symptom corresponding to the above from the doctor order history database and displaying it in the doctor order history display area of the display screen;
A fourth function for transferring the order content selected from the order history information displayed in the order history display area for each doctor in response to the input of the selection command to the order list creation area on the display screen; Electronic medical record ordering integrated control program. An electronic medical record ordering integrated control program according to claim 6,
A fifth function for receiving past medical record reference commands and reading past medical examination information of a specific patient corresponding to the patient identification information from the electronic medical record database and displaying it in the past medical chart reference display area on the display screen; An electronic medical record ordering integrated control program. An electronic medical record ordering integrated control program according to claim 6,
An electronic medical record ordering integrated control program, further comprising a sixth function of learning and recording a current order list displayed and created in the order list creation area in response to an input of an order issuance command in a doctor-specific order history database. A computer-readable recording medium on which the electronic medical record ordering integrated control program according to any one of claims 6 to 8 is recorded.