JP2006178903A - Medical record creation support device, medical record creation program and recording medium - Google Patents

Abstract

<P>PROBLEM TO BE SOLVED: To increase the safety of an electronic medical record system, especially prevent a user from mistaking the patient for whom an input is to be made and enable the user to intuitively grasp the patient's past medical treatment history. <P>SOLUTION: A medical record creation support device comprises a patient information storage means for storing attribute information about patients, a medical record information storage means for storing medical record information about the patients, a reception means for receiving a keyword input from a user, an extraction means for searching the patient information storage means to extract attribute information about patients matching the keyword, a thickness calculation means for calculating thicknesses depending on the patients' medical record information stored in the medical record information storage means, and a display means for displaying the attribute information extracted by the extraction means and images corresponding to the thicknesses calculated by the thickness calculation means. <P>COPYRIGHT: (C)2006,JPO&NCIPI

Description

  The present invention relates to a user support function for the purpose of improving safety in an electronic medical record system. In particular, an object is to prevent a user from making a selection error of a patient to be input.

  Patient medical information (hereinafter referred to as medical chart or medical record information) is stored electronically, and doctors and nurses (hereinafter referred to as users) refer to and update the medical record information by operating the terminal. Electronic medical record systems are generally used.

In such an electronic medical record system, since a specific patient is selected from a large amount of patient information and data is input, a patient selection screen is provided. For example, a specific patient is selected using a patient's name as a search key. (Patent Document 1).
JP 2001-337856 A

  In operation using a paper chart before the introduction of the electronic chart system, the user could intuitively grasp how much the patient had been examined from the thickness of the patient chart. For this reason, even if another patient's medical record was accidentally obtained, the difference could be noticed from the thickness.

  However, with the electronic medical record system, patient information is searched using only text information such as name, and the medical record information is expanded on the screen, so it is necessary to know intuitively what kind of medical examination you have received in the past. There wasn't.

  In addition, it is possible to grasp the detailed medical history by searching the past medical history, but it is necessary for the user to actively perform such operations.

  A medical record creation support apparatus according to the present invention includes a patient information storage unit that stores patient attribute information, a medical record information storage unit that stores patient medical record information, and a reception unit that receives a keyword input from a user. A thickness for calculating the thickness according to the medical record information of the patient stored in the medical record information storage means, and an extraction means for searching the patient information storage means and extracting patient attribute information that matches the keyword And a display means for displaying attribute information extracted by the extraction means and an image corresponding to the thickness calculated by the thickness calculation means.

  According to the present invention, when selecting a patient, an image of the thickness of a medical chart representing the past medical history of each patient is displayed, so that the user can intuitively select a target patient. Become. Furthermore, when the chart information is expanded, an image of the thickness of the chart indicating the past medical history is displayed, so that it is possible to intuitively grasp the past medical history of the patient to be examined.

  In addition, the thickness calculating means calculates the thickness given a predetermined weight determined for each medical practice, so that the thickness given the weight for each medical practice such as examination, hospitalization, and prescription is displayed. It becomes possible to grasp the past history considering the importance of the medical treatment contents, not just the number of medical examinations.

  Further, the thickness calculating means calculates a thickness for each medical practice, and the display means displays an image in which predetermined color coding determined for each medical practice is performed, thereby obtaining a ratio for each medical practice. It becomes possible to grasp.

  Further, the thickness calculating means calculates a thickness for each medical department, and the display means displays an image obtained by performing a predetermined color coding determined for each medical department, so that a ratio for each medical department can be obtained. It becomes possible to grasp.

  In addition, the thickness calculation unit calculates the thickness for each medical practice, and the display unit displays the image for each medical practice, whereby the thickness for each medical practice can be grasped.

  Further, the thickness calculating means calculates the thickness for each medical department, and the display means displays the image for each medical department, thereby making it possible to grasp the thickness for each medical department.

  As described above, since the present invention is configured to display the chart thickness image representing the past medical history of each patient on the patient search screen and the medical chart editing screen, the user can intuitively view the past medical history of the patient. Can be grasped.

  An overview of a system according to an embodiment of the present invention will be described with reference to FIG. FIG. 1 is a system configuration diagram schematically showing a medical record creation support apparatus provided in a medical institution. In the medical institution, the server device 120 and the client terminal 100 are connected via a network 110 such as a LAN. In FIG. 1, only one client terminal 100 is shown. Normally, a plurality of client terminals 100 are connected via a network. However, in this embodiment, since the system configuration of each client terminal 100 is substantially the same, only one is described for convenience of explanation. To do.

  The server device 120 is controlled by the OS 121, and the medical record creation support server system 130 operates on the OS 121. The medical record creation support server system 130 includes a reception program 131 that receives search conditions from the user, an extraction program 132 that extracts patient attribute information that matches the search conditions received by the reception program 131, and patient medical record information. And a display program 134 for displaying search results and chart information on the screen. These programs are stored in an external storage device (not shown) of the server device 120, and are read into the internal storage device when each program is executed. The medical record creation support server system 130 also includes a patient master 140 for storing patient attribute information, a chart data 141 for storing patient chart information, and a thickness management file for storing information related to the thickness of the patient chart. 142, a weight master 143 that stores information about weights when calculating the thickness of the chart, and a thickness image master 144 that stores an image representing the thickness. The program 132, the thickness calculation program 133, and the display program 134 are referred to or updated.

  The server device 120 includes a display control unit 122 that controls a display device (not shown) for presenting various types of information to the user, an input control unit 123 that controls input of information from the user, and a client. And a communication control unit 124 that performs communication control with the terminal 100.

  The client terminal 100 connected to the server device 120 via the network 110 is controlled by the OS 103, and the medical record creation support client system operates on the OS 103. The client terminal 100 is a personal computer, for example. The medical record creation support client system 101 is mainly a browsing program 102, and performs input to the medical record creation support server system 130 and output of information from the medical record creation support server system 130.

  The client terminal 100 includes a display control unit 104 that controls a display device (not shown) for presenting various types of information to the user, an input control unit 105 that controls input of information from the user, and a server. And a communication control unit 106 that performs communication control with the device 120.

  Next, an outline of processing according to an embodiment of the present invention will be described with reference to FIG.

  First, the user performs login processing from the medical record creation support client system 101 of the client terminal 100 to the medical record creation support server system 130 (S201). The reception program 131 of the medical record creation support server system 130 displays a patient search screen on the client terminal 100 after performing user authentication by a general user authentication procedure (S202).

  This patient search screen will be described in detail using the patient search screen 301. The patient search screen 301 includes a header part and a body part. The header part includes a job end button together with the name of the screen. The body portion includes a search key input area for searching for a patient, a search button, and an area for displaying a list of search results.

  In this patient search screen, when the user ends the work, the work end button provided in the header is pressed. When the medical record creation support server system accepts the pressing of the business end button, the business record is ended (S203). If any other operation is accepted, the patient search process of S204 is executed.

  This patient search process will be described in detail using the flow of FIG. First, when the user inputs a search key in the search key input area of the patient search screen 301 and presses the search button, the extraction program 132 accepts the search keyword (S401). In this case, it is assumed that the search is for the patient name and the keyword “Yamada” is accepted.

  Next, the patient master 140 is searched using the keyword, and a matching record is extracted (S402).

  The patient master 140 will be described in detail with reference to FIG. The patient master 501 is a master that stores patient attribute information, and records ID, name, kana, gender, and age. In the search in S402, the Kana item in the patient master 501 is searched using the Kana notation keyword received from the user. Then, the matched record is extracted.

  Next, the thickness management file 142 is searched using the record ID extracted in S402, and a matching record is extracted (S403).

  The thickness management file 142 will be described in detail using the thickness management file 601 of FIG. The thickness management file 601 is a file that stores the thickness of a patient's medical record for each clinical department, and records ID, department, and thickness. In the search of S403, the ID of the thickness management file 601 is searched using the ID of the record extracted in S402. Then, the matched record is extracted.

  Next, the thickness image master 144 is searched using the thickness of the record extracted in S403, and a matching record is extracted (S404).

  The thickness image master 144 will be described in detail using the thickness image file 701 in FIG. The thickness image file 701 is a file that stores an image for each predetermined thickness range, and stores a thickness range and an image. In this case, for convenience of explanation, it is described that an image is stored in a record. However, in practice, for example, pointer information for an image file is stored, and the image itself is stored in another location. Does not matter. In the search of S404, the thickness range of the thickness image file is searched using the thickness of the record extracted in S403. Then, the matched record is extracted.

  When the search of each file is completed, the display program 134 edits the search result list display area on the patient search screen and displays it on the medical record creation support client system 101 (S405).

  The patient search screen displaying a list of the search results will be described in detail using the patient search screen 302 of FIG. The patient search screen 302 is obtained by expanding the search results in the search result list display area of the patient search screen 301, and the search result list display area includes a name, sex, age, and thickness. Among these, the name, gender, and age are transcribed from the patient master 501 extracted in the search of S402. Moreover, about thickness, it expand | deploys as follows. That is, the thickness management file 601 is searched using the record ID extracted in the search of S402. For example, when expanding the display information of Taro Yamada whose attribute information is stored as ID = 0001 in the patient master 501, the ID of the thickness management file is searched using this ID = 0001. As a result, two records of the thickness management file 601 are extracted. Then, by summing up the respective thicknesses, 10 + 20 = 30 is obtained, and the thickness range of the thickness image file 701 is searched using the numerical value of 30. As a result, a record in the thickness range 21 to 30 is extracted, and the image indicated by the record is transferred to the thickness of the search result list display area on the patient search screen 302.

  By repeating these processes for each patient extracted by the search in S402, a search result list display area such as a patient search screen 302 is developed. In this manner, by displaying an image of the thickness of the medical chart representing the past medical history of each patient on the patient search screen, the user can intuitively grasp the past medical history of the patient.

  In the above description, a plurality of image files are prepared, and each image is read and transferred so as to expand the image. However, there are various methods for expanding the image. It is not limited to this method. For example, it is conceivable that only one image is prepared and the same image development is performed by controlling the height designation when displaying.

  Next, the user selects a patient to be input from the search result list display area on the patient search screen 302. In the example of the patient search screen 302, since the screen is created in HTML format and the patient name is clickable, the patient selection is completed when the user clicks the name of the target patient. The patient chart data 141 can be searched and expanded on the chart editing screen.

  This chart editing screen will be described in detail using the chart editing screen 801 of FIG. The chart editing screen 801 is composed of a header part and a body part. The header part includes a patient name and a completed button to be pressed when editing is completed. Further, the body part is divided into two parts on the left and right, and includes an area for displaying a past medical history on the left side and an input area on the right side. Further, a prescription button and an inspection button are provided in the input area. The user inputs an order issued in the current medical care while referring to the past medical history. For example, when issuing a prescription order, a prescription order input tool is activated by pressing a prescription button, and the content is input. Further, when issuing an inspection order, the inspection order input tool is activated by pressing an inspection button, and the contents are input.

  The chart edit screen 801 reads and displays the contents of the chart data 141, and the issue history of each order is written in the chart data 141 as a past medical history.

  The medical chart data 141 will be described in detail using the medical chart data 901 of FIG. The medical chart data 901 is a master for storing patient medical chart data, and records ID, date, category, department, SEQ, item name, and number. The medical record data 901 represents a state in which the history of orders issued in the past for the patient with ID = 0001 is stored. That is, a prescription order was issued in internal medicine on December 9, 2004, and its contents represent that the two records of arinamin are for the third day by the first and second records. In addition, an examination order is issued in the internal medicine on the same day, and the contents indicate that it is TP, Ca in the third to fourth records. The information developed in the past medical history on the medical chart editing screen 801 is information on these medical chart data 901.

  For example, it is assumed that the user has issued a prescription order in internal medicine on December 19, 2004 as shown in the chart editing screen 802 of FIG. And the content shall be that for 2 days arinamin 2 tablets. In this state, when the user presses the done button provided in the header portion, the medical record creation support server system 130 accepts the completion of the input of the chart information (S205). The newly issued order information is recorded in the chart data 901. The chart data 902 in FIG. 9 represents a state in which this recording is completed. The newly added records are the first and second records.

  When the writing to the chart data is completed, the thickness calculation process, which is a feature of the present invention, is executed (S206).

  This thickness calculation process will be described in detail with reference to the flow of FIG. First, the thickness calculation program 133 reads the records added to the chart data 902 in S205 one record at a time (S1001). At this time, if all the records have been processed and there is no unprocessed record, the thickness calculation process (S206) is terminated (S1002). Next, the sequence of the record read in S1001 is determined. If it is 1, the process proceeds to S1004. Otherwise, the process returns to S1001 to read the next record. If SEQ = 1, the weight master 143 is searched using the segment of the record, and a matching record is extracted (S1004).

  The weight master 143 will be described in detail using the weight master 1101 of FIG. The weight master 1101 is a master that stores information for the purpose of controlling weighting for thickness for each medical treatment division, and records the division and the weight. In the search of S1004, the classification of the weight master 1101 is searched using the classification of the record read in S1001. Then, the matched record is extracted. In this case, when the first record of the medical record data 902 is processed, the classification is prescription, so the weight 10 is obtained from the weight master 1101. Then, the information of the thickness management file 601 is updated using the ID and family of the medical record data 902 and the weight 10 obtained in the process of S1004 (S1005). At this time, the thickness management file 601 is searched using the ID or the like. However, when the patient to be processed receives a diagnosis at the first medical department this time, there is no record in the thickness management file 601. Will be created.

  The thickness management file updated in the process of S1005 is exemplified in the thickness management file 602 of FIG. It can be seen that the thickness of the internal medicine is 10 in the thickness management file 601 before the update, and 10 is newly added to 20 this time. Thus, when the thickness of the internal medicine becomes 20, the total thickness of the internal medicine and the surgery becomes 20 + 20 = 40 at the next patient search, and the thickness image file 701 is searched using this thickness 40. Thus, an image having a thickness range of 31 to 50 is displayed.

  When the update of the thickness management file 142 is completed in S1005, the process returns to S1001, and the next additional record of the chart data is read.

  As described above, since the thickness management file 142 is updated every time a medical chart is edited, the latest medical chart thickness can always be displayed immediately at the time of patient search. If importance is not placed on the immediacy of display, it is also possible to search the patient chart data at the time of patient search and perform the same thickness calculation as described above at the timing of displaying the search result. In addition to such an occasional process, it is also possible to perform a thickness calculation process for a plurality of patients by a batch process such as daily or monthly.

  Although this embodiment has been described as an example of a general client-server system, a system using a personal computer alone can be considered in a small medical institution. In that case, a similar mechanism can be realized by providing the browsing program 102 provided in the medical record creation support client system in the medical record creation support server system.

  In the present embodiment, the thickness of the entire patient chart is displayed as in the search result screen 302. However, the thickness management file 142 holds the thickness for each department. It is also possible to display the thickness of each department as a separate image. Furthermore, the thickness management file 142 is not managed for each medical department but for each medical department, so that the thickness for each medical department can be displayed as a separate image. In addition, it may be possible to display images with higher readability by using different colors of images to be displayed for each medical department or for each medical department.

  Further, in the present embodiment, the image representing the thickness of the medical chart has been described to be displayed in the search result list display area of the search result screen 302. It is also possible to make it possible for the user to intuitively know the past medical history.

  In addition, each program described in this embodiment can be distributed by storing it in a recording medium such as a CD-ROM, and by installing the program in a computer using such a recording medium, the above-described program can be distributed. Such processing is possible.

  Regarding the above embodiment, the following additional notes are disclosed.

(Appendix 1)
Patient information storage means for storing patient attribute information;
Medical record information storage means storing patient medical record information;
An accepting means for accepting keyword input from a user;
An extraction means for searching the patient information storage means and extracting patient attribute information matching the keyword;
A thickness calculating means for calculating a thickness according to the medical record information of the patient stored in the medical record information storage means;
Display means for displaying attribute information extracted by the extraction means and an image corresponding to the thickness calculated by the thickness calculation means;
A medical record creation support device characterized by comprising:

(Appendix 2)
2. The medical record creation support apparatus according to appendix 1, wherein the thickness calculating means calculates a thickness given a predetermined weight determined for each medical practice.

(Appendix 3)
The thickness calculation means calculates the thickness for each medical practice,
2. The medical record creation support apparatus according to appendix 1, wherein the display means displays an image that has been subjected to predetermined color coding determined for each medical practice.

(Appendix 4)
The thickness calculation means calculates the thickness for each department,
The medical record creation support apparatus according to appendix 1, wherein the display means displays an image obtained by performing predetermined color coding determined for each medical department.

(Appendix 5)
The thickness calculation means calculates the thickness for each medical practice,
The medical record creation support apparatus according to appendix 1, wherein the display means displays an image for each medical practice.

(Appendix 6)
The thickness calculation means calculates the thickness for each department,
The medical record creation support apparatus according to appendix 1, wherein the display unit displays an image for each medical department.

(Appendix 7)
Computer
Patient information storage means for storing patient attribute information;
Medical record information storage means storing patient medical record information;
An accepting means for accepting keyword input from a user;
An extraction means for searching the patient information storage means and extracting patient attribute information matching the keyword;
A thickness calculating means for calculating a thickness according to the medical record information of the patient stored in the medical record information storage means;
A medical record creation program that operates as display means for displaying attribute information extracted by the extraction means and an image corresponding to the thickness calculated by the thickness calculation means.

(Appendix 8)
Computer
Patient information storage means for storing patient attribute information;
Medical record information storage means storing patient medical record information;
An accepting means for accepting keyword input from a user;
An extraction means for searching the patient information storage means and extracting patient attribute information matching the keyword;
A thickness calculating means for calculating a thickness according to the medical record information of the patient stored in the medical record information storage means;
A computer-readable recording of a medical record creation program that operates as display means for displaying attribute information extracted by the extraction means and an image corresponding to the thickness calculated by the thickness calculation means recoding media.

It is a system configuration figure of an embodiment. It is a processing flow of an embodiment. It is a figure which shows an example of a patient search screen. It is a flowchart which shows the flow of a patient search process. It is a figure which shows an example of a patient master. It is a figure which shows an example of a thickness management file. It is a figure which shows an example of a thickness image file. It is a figure which shows an example of a medical chart edit screen. It is a figure which shows an example of medical chart data. It is a flowchart which shows the flow of thickness calculation processing. It is a figure which shows an example of a weight master.

Explanation of symbols

DESCRIPTION OF SYMBOLS 100 Client terminal 101 Medical record creation support client system 102 Browsing program 103 OS
104 Display Control Unit 105 Input Control Unit 106 Communication Control Unit 110 Network 120 Server Device 121 OS
122 display control unit 123 input control unit 124 communication control unit 130 medical record creation support server system 131 reception program 132 extraction program 133 thickness calculation program 134 display program 140 patient master 141 chart data 142 thickness management file 143 weight master 144 thickness image Master

Claims (3)

Patient information storage means for storing patient attribute information;
Medical record information storage means storing patient medical record information;
An accepting means for accepting keyword input from a user;
An extraction means for searching the patient information storage means and extracting patient attribute information matching the keyword;
A thickness calculating means for calculating a thickness according to the medical record information of the patient stored in the medical record information storage means;
Display means for displaying attribute information extracted by the extraction means and an image corresponding to the thickness calculated by the thickness calculation means;
A medical record creation support device characterized by comprising: Computer
Patient information storage means for storing patient attribute information;
Medical record information storage means storing patient medical record information;
An accepting means for accepting keyword input from a user;
An extraction means for searching the patient information storage means and extracting patient attribute information matching the keyword;
A thickness calculating means for calculating a thickness according to the medical record information of the patient stored in the medical record information storage means;
A medical record creation program that operates as display means for displaying attribute information extracted by the extraction means and an image corresponding to the thickness calculated by the thickness calculation means. Computer
Patient information storage means for storing patient attribute information;
Medical record information storage means storing patient medical record information;
An accepting means for accepting keyword input from a user;
An extraction means for searching the patient information storage means and extracting patient attribute information matching the keyword;
A thickness calculating means for calculating a thickness according to the medical record information of the patient stored in the medical record information storage means;
A computer-readable recording of a medical record creation program that operates as display means for displaying attribute information extracted by the extraction means and an image corresponding to the thickness calculated by the thickness calculation means recoding media.

Images