JP2006139389A - Program for creating medical record - Google Patents

Abstract

<P>PROBLEM TO BE SOLVED: To reduce the operational burden of inputting medical practice information to a medical record (electronic medical record) that is created electronically and stored electronically. <P>SOLUTION: A program for creating medical records is provided. The program makes a computer execute an editing screen providing procedure for providing an editing screen for editing medical records; an input tool starting procedure for starting each input tool of a set of input tools consisting of input tools for inputting medical practice information to a medical record edited on the editing screen, when the name of a patient's disease is designated on the editing screen, each of the input tools being registered in a registration destination with the name of the disease added; and a medical record storage procedure for storing the medical record edited on the editing screen in a storage destination. <P>COPYRIGHT: (C)2006,JPO&NCIPI

Description

  The present invention relates to a medical record creation program for creating a medical record.

  In recent years, electronic medical records (electronic medical records) that are created electronically and stored electronically are used in medical institutions. In an individual hospital or the like, an environment for using an electronic medical record may be realized by a stand-alone computer. However, in a general hospital or the like, an environment for using an electronic medical record may be realized by a client / server type computer system. This is because it is possible to share electronic medical records.

  The medical information is input to the electronic medical record by activating an input tool for inputting the medical information to the electronic medical record. Launch template tool and enter findings, launch schema tool and enter schema, launch prescription order tool and enter prescription order to pharmacist, launch test order tool and test technician For example, an inspection order is entered, a radiation order tool is activated, and a radiation order is entered for a radiologist. Therefore, a doctor who is undergoing medical treatment is forced to interrupt his / her thinking during medical treatment by inputting medical information to the electronic medical record.

Patent Document 1 discloses an invention for reducing the work load of inputting medical information to an electronic medical record. In the invention described in Patent Literature 1, medical information input to a certain electronic medical record is registered as a set, and the set can be used when inputting medical information to another electronic medical record. The burden of inputting medical information to an electronic medical record is reduced.
JP 2000-259740 A

  However, in the invention described in Patent Document 1, when inputting medical information to an electronic medical record of a patient, it is convenient to use a set of symptoms having high similarity to the patient's symptoms, Using a set of symptoms that are low in similarity to the patient's symptoms is inconvenient with many corrections. However, if a large number of sets are registered, it becomes difficult to search for a desired set. Therefore, in the end, it was almost impossible to use the set, and most of them entered medical information into the electronic medical record from the beginning.

  An object of the present invention is to reduce the work burden of inputting medical information into a medical record regarding a medical record (electronic medical record) that is created electronically and stored electronically.

  The present invention is a medical record creation program for creating a medical record, an editing screen providing procedure for providing an editing screen for editing a medical record, and a disease name of a patient's disease specified on the editing screen. Then, the input tool is started to start each input tool of the input tool set that is registered in the registration destination with the name of the disease attached, including an input tool for inputting medical information to the medical record edited on the editing screen. The present invention relates to a medical record creation program for causing a computer to execute a procedure and a medical record storage procedure for storing a medical record edited on the editing screen in a storage destination.

  The present invention is also a medical record creation program for creating a medical record, an editing screen providing procedure for providing an editing screen for editing a medical record, and a medical record edited on the editing screen. Input tool set registration procedure to register the input tool set consisting of input tools for inputting information with the disease name attached to the registration destination, and when the disease name of the patient's disease is specified on the edit screen, the disease name is attached The input tool activation procedure for activating each input tool of the input tool set registered at the registration destination and the medical record saving procedure for saving the medical record edited on the editing screen to the storage destination are executed on the computer. It relates to a medical record creation program.

  The present invention also provides a medical record creation device realized by executing the medical record creation program, a computer-readable recording medium storing the medical record creation program, as means for solving the above problems, It can also be.

  The present invention makes it possible to reduce the work burden of inputting medical information into a medical record regarding a medical record (electronic medical record) created electronically and stored electronically.

  FIG. 1 shows an example of an environment for using an electronic medical record. In FIG. 1, the use environment of the electronic medical record is realized by a client / server type computer system. In FIG. 1, an electronic medical record client 101 and an electronic medical record server 102 are interconnected by a LAN (local area network).

  The electronic medical record client 101 is a device for electronically creating an electronic medical record. As shown in FIG. 2, an OS 211 and an electronic medical record client program 221 are installed in the HDD 201 of the electronic medical record client 101. The electronic medical record client program 221 is a program for electronically creating an electronic medical record. The electronic medical record client 101 is, for example, a PC (personal computer) in which the electronic medical record client program 221 is installed by a CD-ROM 231 in which the electronic medical record client program 221 is recorded.

  The electronic medical record server 102 is a device for electronically storing electronic medical records. As shown in FIG. 2, an OS 212 and an electronic medical record server program 222 are installed in the HDD 202 of the electronic medical record server 102. The electronic medical record server program 222 is a program for electronically storing electronic medical records. The electronic medical record server 102 is, for example, a PC (personal computer) in which the electronic medical record server program 222 is installed by a CD-ROM 232 in which the electronic medical record server program 222 is recorded.

  In the electronic medical record client 101, the electronic medical record is edited by activating an “editing screen” for editing the electronic medical record, and the input of medical information to the electronic medical record is performed by the electronic data edited on the editing screen. The “input tool” for inputting medical information into the medical chart is activated and executed.

  The electronic medical record client 101 includes, as function blocks realized by the electronic medical record client program 221, an edit screen providing unit 111, a disease name master reference unit 112, a disease name setting unit 113, a disease name reference unit 114, and a set registration unit 115. A set development unit 116, a tool activation unit 117, and a chart storage unit 118.

  The edit screen providing unit 111 is a functional block that provides an edit screen. The disease name master reference unit 112 is a functional block that refers to the disease name master 121. The disease name setting unit 113 is a functional block that sets a disease name as a setting destination (disease name table 122). The disease name reference unit 114 is a functional block that refers to the disease name set in the setting destination (the disease name table 122). The set registration unit 115 is a functional block that registers an input tool set including input tools in a registration destination (set table 123). The set expansion unit 116 is a functional block that expands the input tool set registered in the registration destination (set table 123). The tool activation unit 117 is a functional block that activates each input tool of the input tool set registered in the set table 123 and the input tool of the tool table 124. The medical chart storage unit 118 is a functional block that stores the electronic medical chart edited on the editing screen in a storage destination (the medical chart table 125).

  FIG. 3 is a flowchart for explaining an electronic medical record editing process. The electronic medical record editing process will be described below with reference to the step numbers in the flowchart of FIG.

  FIG. 4 is a screen view of a login screen. In the login screen of FIG. 4, a user (such as a doctor) can log in by entering a user ID and a user password. When the user logs in on the login screen of FIG. 4 (S101), the screen moves to FIG.

  FIG. 5 is a screen view of a patient selection screen. In the patient selection screen of FIG. 5, a user (doctor or the like) can select a patient by inputting a patient ID. When the user selects a patient on the patient selection screen of FIG. 5 (S102), the screen moves to FIG.

  FIG. 6 is a screen view of the editing screen. In the editing screen of FIG. 6, the user “Doctor Ichiro” who has logged in on the login screen can edit the electronic medical record of the patient “Patient Taro” selected on the patient selection screen. A region A on the left side of the editing screen in FIG. 6 is a display region in which the electronic medical record of the patient created and saved up to the previous time is displayed. A region B on the right side of the editing screen in FIG. 6 is an editing region for editing the patient's electronic medical record. The function for providing the edit screen of FIG. When the disease name setting tag C is pressed on the editing screen of FIG. 6 (S103), the window of FIG. 7 is opened.

  FIG. 7 is a screen view of the editing screen in a state where the disease name setting window is opened. In the disease name setting window of FIG. 7, a disease name to be displayed on the edit screen as a designation candidate for designating a disease name of a patient on the edit screen can be set for each patient. That is, in the disease name setting window of FIG. 7, the disease name to be displayed on the editing screen of FIG. 6 as the designation candidate for designating the disease name of the patient “patient Taro” on the editing screen of FIG. It can be set as a setting destination exclusively. Since the disease name set in the disease name setting window of FIG. 7 is dedicated to each patient but not to each user, the user “Doctor Ichiro” does not necessarily need to set the disease name of the patient “Patient Taro” himself. Absent. The function of acquiring disease name setting candidates with reference to the disease name master 121 is performed by the disease name master reference unit 112. The function of setting the disease name in the disease name table 122 is performed by the disease name setting unit 113. When a disease name is set in the disease name setting window of FIG. 7 (S104), the window of FIG. 7 is closed.

  FIG. 8 is a screen view of the editing screen in a state where the disease name setting window is closed. It is the state which returned to the edit screen of FIG. The disease name “gastritis, allergic rhinitis, pneumonia” displayed on the editing screen of FIG. 8 is a designation candidate for designating the disease name of the patient “patient Taro” on the editing screen of FIG. Note that the disease name displayed on the editing screen of FIG. 8 is already displayed on the editing screen of FIG. The disease name reference unit 114 has a function of referring to disease names set in the disease name table 122 and acquiring candidate designations of disease names. When the disease name “gastritis” of the patient “patient Taro” is designated on the editing screen of FIG. 8 (S105), the screen shifts to the screen of FIG.

  FIG. 9 is a screen diagram of the editing screen in a state where the input tool is activated. When the disease name “gastritis” of the patient “Patient Taro” is specified on the edit screen, as shown in FIG. 9, the disease name “gastritis” consists of an input tool for inputting medical information to the electronic medical record edited on the edit screen. ”Is automatically expanded (S106), and each input tool of the input tool set is automatically activated (S107). Here, since the input tool set consisting of the input tools “prescription order tool D, examination order tool E, template tool F, schema tool G” is registered with the disease name “gastritis” in the registration destination, the input tool Each set of input tools “prescription order tool D, inspection order tool E, template tool F, schema tool G” is activated. The input tool set registration process will be described later. The function of expanding the input tool set registered in the set table 123 is performed by the set expanding unit 116. The tool activation unit 117 has a function of activating each input tool of the input tool set registered in the set table 123.

  In this way, on the edit screen, when a disease name is specified, each input tool of the input tool set registered with the disease name is automatically started, so clinical information is entered into the electronic medical record of a patient with gastritis If you register an input tool set often used as an input tool set with a disease name “gastritis” attached, you can simply specify the disease name “gastritis” and edit the medical information in the electronic medical record of the patient with gastritis. An input tool that is frequently used for input is automatically started. As a result, the medical doctor who is performing medical care can concentrate exclusively on the input operation (what to input) of the medical information without being bothered by the input tool starting operation (what to start) when inputting medical information on the electronic medical record. As a result, the work burden of inputting medical information to the electronic medical record is reduced. When a right click operation is performed on the editing screen of FIG. 9, the screen moves to the screen of FIG.

  FIG. 10 is a screen diagram of the editing screen in a state where the save button is displayed. When a right click operation is performed on the edit screen, a save button H for saving the electronic medical record edited on the edit screen to the save destination is displayed as shown in FIG. When the save button H is pressed on the edit screen (S108), the electronic medical record edited on the edit screen is saved in the save destination (S109) and displayed in the area B (edit area) as shown in FIG. The contents are moved to area A (display area). The medical chart storage unit 118 has a function of storing the electronic medical chart edited on the editing screen in the medical chart table 125. When the end button I is pressed (S110) on the editing screen of FIG. 11, the process proceeds to the patient selection screen (S111) of FIG. It is the state which returned to the patient selection screen of FIG. When the user logs out on the patient selection screen of FIG. 12, the login screen (S112) of FIG. 13 is displayed. It is the state which returned to the login screen of FIG.

  The input tool set registration process will be described below.

  FIG. 14 is a screen view of the set registration screen. When the user presses the set registration button on the patient selection screen in FIG. 5, the screen moves to the set registration screen (S201) in FIG. In the set registration screen shown in FIG. 14, an input tool set including input tools for inputting medical information to the electronic medical record edited on the editing screen can be created. To create an input tool set consisting of the input tools “prescription order tool D, inspection order tool E, template tool F, schema tool G”, as shown in FIG. 14, the input tool “prescription order tool D, inspection order tool” E, template tool F, schema tool G "shall be manually activated. On the set registration screen of FIG. 14, an activation button J for manually activating the input tool is displayed. When a right click operation is performed on the set registration screen of FIG. 14, the window of FIG. 15 opens.

  FIG. 15 is a screen view of the set registration screen in a state where the disease name attachment window is opened. When a right click operation is performed on the set registration screen, the disease name attachment window (S202) in FIG. 15 is opened. In the disease name attachment window of FIG. 15, search for a disease name attached to the input tool set created on the set registration screen, and register the input tool set created on the set registration screen with the disease name attached to the registration destination. Can do. The input tool set registered in the disease name attachment window of FIG. 15 is not dedicated to each patient or user, and therefore the doctor “Doctor Ichiro” does not necessarily have to register the input tool set himself. The function of acquiring disease name attachment candidates with reference to the disease name master 121 is performed by the disease name master reference unit 112. The function of registering the input tool set in the set table 123 with the disease name attached is the responsibility of the set registration unit 115. When the set registration button K is pressed in the disease name attachment window of FIG. 15 (S203), the input tool set created on the set registration screen is attached with the disease name searched in the disease name attachment window and registered in the registration destination (S204). Move to the patient selection screen of FIG. It is the state which returned to the patient selection screen of FIG.

  Hereinafter, data structures of various masters and various tables will be described.

  FIG. 16 is a structural diagram for explaining the data structure of the disease name master 121. As shown in the figure, in the disease name master 121, the disease name is managed with management items such as “disease name code, disease name”.

  FIG. 17 is a structural diagram for explaining the data structure of the disease name table 122. As shown in the figure, in the disease name table 122, disease names are managed with management items such as “disease name code, disease name, patient ID, patient name” and the like.

  FIG. 18 is a structural diagram for explaining the data structure of the set table 123. As shown in the figure, in the set table 123, the input tool set is managed with management items such as “set number, set name, set content, disease name code, disease name” and the like. As shown in the figure, the set contents are further managed with management items such as “tool number, tool name, tool contents”.

  FIG. 19 is a structural diagram for explaining the data structure of the tool table 124. As shown in the figure, in the tool table 124, input tools are managed with management items such as “tool number, tool name, tool content”.

  FIG. 20 is a structural diagram for explaining the data structure of the chart table 125. As shown in the figure, in the medical chart table 125, the electronic medical chart is managed with management items such as "medical chart number, medical chart name, medical chart contents, patient ID, patient name" and the like. As shown in the figure, the contents of the medical chart are described and managed in XML (extensible Markup Language) here.

The invention is not limited to the specifically disclosed embodiments, and various modifications and embodiments are possible without departing from the scope of the invention as claimed in the claims. Finally, an additional note will be described.
(Appendix 1)
A medical record creation program for creating a medical record,
An edit screen providing procedure for providing an edit screen for editing a medical record;
When the disease name of the patient's disease is specified on the edit screen, the input includes the input tool for inputting medical information to the medical record edited on the edit screen and the disease name is attached and registered in the registration destination Input tool startup procedure for starting each input tool in the toolset,
A medical record creation program for causing a computer to execute a medical record storage procedure for storing a medical record edited on the editing screen in a storage destination.
(Appendix 2)
A medical record creation program for creating a medical record,
An edit screen providing procedure for providing an edit screen for editing a medical record;
An input tool set registration procedure for registering an input tool set consisting of an input tool for inputting medical information in a medical record edited on the editing screen with a disease name attached to a registration destination;
When a disease name of a patient's disease is specified on the edit screen, an input tool activation procedure for activating each input tool of the input tool set attached with the disease name and registered in the registration destination;
A medical record creation program for causing a computer to execute a medical record storage procedure for storing a medical record edited on the editing screen in a storage destination.
(Appendix 3)
The supplementary note 1 or 2 that causes a computer to execute a disease name setting procedure for setting a disease name to be displayed on the edit screen as a designation candidate for designating a disease name of a patient's disease on the edit screen for each patient. Medical record creation program.
(Appendix 4)
A computer-readable recording medium that records a medical record creation program for creating a medical record,
An edit screen providing procedure for providing an edit screen for editing a medical record;
When the disease name of the patient's disease is specified on the edit screen, the input includes the input tool for inputting medical information to the medical record edited on the edit screen and the disease name is attached and registered in the registration destination Input tool startup procedure for starting each input tool in the toolset,
A computer-readable recording medium recording a medical record creation program for causing a computer to execute a medical record storage procedure for storing a medical record edited on the editing screen in a storage destination.
(Appendix 5)
A computer-readable recording medium that records a medical record creation program for creating a medical record,
An edit screen providing procedure for providing an edit screen for editing a medical record;
An input tool set registration procedure for registering an input tool set consisting of an input tool for inputting medical information in a medical record edited on the editing screen with a disease name attached to a registration destination;
When a disease name of a patient's disease is specified on the edit screen, an input tool activation procedure for activating each input tool of the input tool set attached with the disease name and registered in the registration destination;
A computer-readable recording medium recording a medical record creation program for causing a computer to execute a medical record storage procedure for storing a medical record edited on the editing screen in a storage destination.
(Appendix 6)
A medical record creation device for creating a medical record,
An edit screen providing means for providing an edit screen for editing the medical record;
When the disease name of the patient's disease is specified on the edit screen, the input includes the input tool for inputting medical information to the medical record edited on the edit screen and the disease name is attached and registered in the registration destination An input tool starting means for starting each input tool of the toolset;
A medical record creation device comprising medical record storage means for storing a medical record edited on the editing screen in a storage destination.
(Appendix 7)
A medical record creation device for creating a medical record,
An edit screen providing means for providing an edit screen for editing the medical record;
An input tool set registration means for registering an input tool set consisting of an input tool for inputting medical information in a medical record edited on the editing screen, with a disease name attached to a registration destination;
When a disease name of a patient's disease is designated on the edit screen, an input tool activation unit that activates each input tool of the input tool set that is attached to the registration destination with the disease name attached thereto;
A medical record creation device comprising medical record storage means for storing a medical record edited on the editing screen in a storage destination.

An example of the usage environment of an electronic medical record is shown. It is a figure for demonstrating the example of the implementation method of the utilization environment of an electronic medical chart. It is a flowchart for demonstrating the edit process of an electronic medical chart. It is a screen figure of a login screen. It is a screen figure of a patient selection screen. It is a screen figure of an edit screen. It is a screen figure of the edit screen of the state which opened the disease name setting window. It is a screen figure of the edit screen of the state which closed the disease name setting window. It is a screen figure of the edit screen of the state which started the input tool. It is a screen figure of the edit screen of the state which displayed the save button. It is a screen figure of an edit screen. It is a screen figure of a patient selection screen. It is a screen figure of a login screen. It is a screen figure of a set registration screen. It is a screen figure of a set registration screen in a state where a disease name attachment window is opened. It is a structure figure for demonstrating the data structure of a disease name master. It is a structure figure for demonstrating the data structure of a disease name table. It is a structural diagram for demonstrating the data structure of a set table. It is a structural diagram for demonstrating the data structure of a tool table. It is a structure figure for demonstrating the data structure of a medical chart table.

Explanation of symbols

DESCRIPTION OF SYMBOLS 101 Electronic medical record client 102 Electronic medical record server 111 Editing screen provision part 112 Disease name master reference part 113 Disease name setting part 114 Disease name reference part 115 Set registration part 116 Set expansion part 117 Tool starting part 118 Medical record preservation | save part 121 Disease name master 122 Disease name table 123 set Table 124 Tool table 125 Medical record table 201 HDD
202 HDD
211 OS
212 OS
221 Electronic medical record client program 222 Electronic medical record server program 231 CD-ROM
232 CD-ROM

Claims (3)

A medical record creation program for creating a medical record,
An edit screen providing procedure for providing an edit screen for editing a medical record;
When the disease name of the patient's disease is specified on the edit screen, the input includes the input tool for inputting medical information to the medical record edited on the edit screen and the disease name is attached and registered in the registration destination Input tool startup procedure for starting each input tool in the toolset,
A medical record creation program for causing a computer to execute a medical record storage procedure for storing a medical record edited on the editing screen in a storage destination. A medical record creation program for creating a medical record,
An edit screen providing procedure for providing an edit screen for editing a medical record;
An input tool set registration procedure for registering an input tool set consisting of an input tool for inputting medical information in a medical record edited on the editing screen with a disease name attached to a registration destination;
When a disease name of a patient's disease is specified on the edit screen, an input tool activation procedure for activating each input tool of the input tool set attached with the disease name and registered in the registration destination;
A medical record creation program for causing a computer to execute a medical record storage procedure for storing a medical record edited on the editing screen in a storage destination. The computer executes a disease name setting procedure for setting a disease name for display on the edit screen as a designation candidate for designating a disease name of a patient's disease on the edit screen for each patient. A program for creating medical records.

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