JP2008176596A - Medical care support device, medical care support method, and medical care supporting program - Google Patents

Abstract

<P>PROBLEM TO BE SOLVED: To provide an electronic medical record device by which an input work is simplified as much as possible. <P>SOLUTION: The medical care support device is provided with: a sheet file which stores setup information on a sheet input screen for inputting medical care information and is stored by a storage means; a display control means for reading the setup information from the sheet file to display the sheet input screen to a display means; a sheet setting means for setting input entries of a procedure, prescription or the like in a sheet input screen and storing the setting information in the sheet file and controlling them; and a medical care information storage control means for storing and controlling an input item which is selected and input in the sheet input screen to a medical care information file of a patient. The sheet setting means sets a plurality of tabs for every sheet in response to designation, stores and controls them together with the input respective names in the sheet file, switches the tabs displayed to the sheet input screen with a selection input means, and selects and inputs items to be input. <P>COPYRIGHT: (C)2008,JPO&INPIT

Description

  The present invention relates to a medical assistance device or an electronic medical record device that records information related to medical treatment of a patient, and more particularly to a method for inputting medical data.

In a medical institution, a medical assistance device so-called an electronic medical record device that records the treatment contents and the like for a patient is becoming popular. In this medical support device, the name of the patient diagnosed when the doctor treated the patient, the medical data indicating the treatment contents such as the treatment, prescription, and examination performed on the patient, the patient's chief complaint and doctor's findings, Data such as progress is also recorded. Therefore, in the conventional medical assistance device, the input of the disease name for inputting the name of the wound, the input of the prescription for inputting the treatment, the prescription, etc., and the input of the main complaint, the findings, the progress for inputting the progress data, etc. Business is usually prepared. Each business has a disease name input screen, a prescription input screen, a progress input screen, and the like, and switches to each business, that is, switches to each screen and inputs data. For example, Patent Document 1 describes a dental care support device that first displays a disease name input screen and switches to a treatment input screen when a disease name is selected there.
JP 2000-36004 A

  An example of a conventional disease name input screen is shown in FIG. Here, a disease name input screen is superimposed on a medical record No. 2 paper screen that displays registered medical data like a paper medical record. If the doctor wants to enter “depression” here, click “A” on the upper left of the disease name input screen, and click the desired “Depression” from the list of “A” on the list. To display in the lower current medical history column. The name of the wound currently being treated is displayed here. The start date, outcome, insurance information, etc. are automatically displayed by the device. Then, the disease name data is registered in the database by instructing the OK button at the lower right.

  Since there are hundreds of wound names used in Japan, conventionally, a list of disease names is first displayed according to some classification, and a desired disease name is selected and designated from among the list and registered. Of course, when the number of disease names included in the displayed list is large, it is necessary to further scroll the list. Similarly, when inputting prescriptions and examinations, it is a procedure to specify a name and other classifications, first display a list, and select a desired one from the list. Furthermore, the selection of drugs related to the prescription is more troublesome because there are cases where the classification extends to two layers and three layers.

  By the way, it is known that the patient's disease name is biased depending on the department. Depending on the department, if you select a few of the names of the diseases you see in the department, you will often be able to cover the majority of patients with those names. Along with this, inspections, prescriptions, etc. are often carried out with similar items. However, conventionally, as described above, for example, when inputting a disease name, a disease name input operation is started for any patient, a disease name input screen is displayed, classification designation, list display, and disease name selection instruction procedure It was necessary to step on. The same procedure was used for prescription and inspection. This has been a burden for doctors operating electronic medical records in busy clinical settings. Therefore, an object of the present application is to provide an electronic medical chart apparatus in which input is simplified as much as possible.

  The present invention is a medical assistance device that includes an input means, a display means, and a storage means, and inputs and registers patient medical information in a medical institution, and holds patient medical information and is stored in the storage means A medical information file, a sheet file that stores setting information of a sheet input screen for inputting medical information, is stored in the storage unit, and setting information is read from the sheet file and a sheet input screen is displayed on the display unit Display control means, sheet setting means for setting input items such as treatment and prescription on the sheet input screen and controlling the setting information to be stored in the sheet file, and desired input items on the sheet input screen displayed on the display means The selection input means for selecting and inputting the items and the input items selected and input on the sheet input screen are stored in the medical information file of the patient. Medical information storage control means, wherein the sheet setting means sets a plurality of tabs for each sheet in accordance with an instruction, controls storage in the sheet file together with each inputted name, and the selection input means Solves the above problem by switching the tabs displayed on the sheet input screen and selectively inputting the input items.

  According to the medical assistance device of the present invention, medical data can be input by simply checking on the screen what is necessary for the patient among the input items set on the sheet. At that time, a large number of items can be input together in one sheet by switching tabs. In addition, by setting a label on the sheet, the medical data is registered as one prescription within the range delimited by the label, so that the labor of repeating registration for each prescription is reduced.

  FIG. 1 shows a block configuration of the medical assistance device 10 according to the embodiment of the present invention. In the figure, 4 is a display device as an information display means composed of an LCD or the like, 5 is a keyboard as data input means, 6 is a pointing device such as a mouse, 1 is a control device including a CPU 2 and a memory 3, and 7 is a hard disk. It is a file device composed of storage means such as a device. The file device 7 stores a sheet file 11, a disease name file 12, a treatment file 13, a patient file 14, and a medical treatment information file 15. The control device 1 has a function of receiving input from the keyboard 5 and the pointing device 6, a function of controlling the display of the display device 4, and a function of controlling the entire device 10. The keyboard 5 and the pointing device 6 function as selection means or selection input means in the following description. The medical assistance device 10 may be a basic computer such as a general computer such as a personal computer. Then, a program having a function specific to this apparatus may be installed in a ROM or a file device in advance, or stored in a storage medium such as a CD-ROM, or may be supplied via a network. May be placed downloadable. When the control device 1 introduces and executes the program, functions unique to the present device are exhibited.

  The patient file 14 stores patient-specific information such as the patient's name and address, and insurance information. The medical information file 15 stores information related to medical care such as treatments, prescriptions, examinations, and disease names of the patients for each patient. In the disease name file 12, all wound disease names that may be used in this medical institution are registered in advance together with their unique disease name codes. In the treatment file 13, items such as medical treatments such as treatments and examinations, medicines and prescriptions, main complaints, findings, and vitals, which are items to be recorded in the medical record, are registered in advance along with their names and unique codes. The sheet file 11 stores information on a sheet in which the input of medical treatment contents is standardized.

  Here, the sheet input and sheet unique to the present application will be described. FIG. 5 shows a state where the sheet input screen 100 is displayed by instructing sheet input. The screen 200 in the background is a basic screen when this patient is called, and the sheet input screen 100 is displayed on the basic screen 200. Since there is a button 201 for instructing sheet input at the right end of the basic screen 200, the user instructs the button 201 with the pointing device 6, that is, clicks the button 201 to display the sheet input screen 100. Above the button 201 are a disease name input button, a prescription input button, and a progress input button, which are buttons for calling a conventional disease name input screen, prescription input screen, and progress input screen, respectively.

  One sheet is displayed as the sheet input screen 100, and FIG. 4 schematically shows the configuration of the sheet. In this embodiment, the user can freely design and register a sheet. The sheet includes a top header section, a selection input section composed of a plurality of columns (column 1, column 2,...), And a bottom footer section. The header part displays a doctor name, a department name, insurance information, and the like. The footer section includes buttons for instructing data registration, and a pull-down menu and tab for selecting a registered sheet.

  Up to eight columns can be set in the selection input section, and each column has a setting column for 40 rows. The user can freely set input items in this setting field. At this time, the control unit 1 functions as a sheet setting unit. FIG. 3 and FIGS. 6 to 8 show how the input items are additionally set. FIG. 6 shows the original sheet input screen 100, where the name of the currently open sheet, here “input of progress” is displayed in the sheet selection menu 101. FIG. 7 shows an instruction to change the sheet (step S21 in FIG. 3) and the sheet change screen 110 is displayed (S22). The sheet change screen 110 is a copy of the original sheet input screen 100, and what is added or deleted and finally OK (S33: Yes) is reflected in the original sheet input screen 100. It is. In FIG. 7, in order to additionally set items such as progress on the sheet change screen 110, the lower left progress button 113 is instructed (S23), the progress input tool 120 is displayed, and "body temperature" is selected and instructed ( (S24). As a result, the body temperature input item 116, that is, the top check box, the name “body temperature”, and the unit “° C.” are displayed on the sheet change screen 110 in a form added to the initial sheet change screen 110.

  Further, the progress input tool 120 is closed, the next prescription button 114 is instructed (S25), and the prescription input tool 130 is displayed in FIG. Here, the arten lock (2 mg) of the prescription input tool 130 is instructed (S26), and the check box of the arten lock input item 117 and its name are additionally displayed on the sheet change screen 110. I understand. Then, when the registration of this change is instructed (S33; Yes), the control unit 1 registers the setting contents in the sheet file 11, and additionally displays the input items of body temperature and arten lock on the original sheet input screen 100. (S36). It is also possible to set an input item related to a disease name by instructing the disease name button 115 to display a disease name input tool (not shown). The input item is set as a combination of “name” and any or all of “input”, “numerical value”, and “unit”. “Input” is data of the input item, and is a specific numerical value or comment sentence that the doctor inputs from the keyboard 5 or the like.

  The sheet input is such that medical data can be input by simply checking on the screen the necessary items for the patient among the input items set on the sheet using a pointing device. Therefore, input items that are likely to be used may be set and registered in advance in the sheet. For example, some names of wounds often found in the department, drugs and prescriptions often prescribed in the department, vital items such as patient complaints, doctor's findings, body temperature, blood pressure, and the like. These may be divided into columns as a disease name relationship, a prescription relationship, a progress relationship, etc., and set in a sheet, or may be mixed in the same column. In this embodiment, the user can freely determine how to arrange the sheet in the sheet. A plurality of sheets can be registered with different settings for each sheet, with each assigned a name. Sheet switching is performed by selecting a desired sheet name from the sheet selection menu 101.

  A label can be set on the sheet. The label is used to group input items in the column. The label button 111 is instructed on the sheet change screen 110, a label can be set by the same operation as the input item, and a free name can be given. The label is displayed with an underline on the sheet input screen 100 so as to be easily understood visually. Labels also have the ability to separate prescriptions. For example, the labels of prescription 1 and prescription 2 may be set in the same column, and one or more medicine input items may be set under each label.

  Further, the size when displaying the sheet input screen 100 and the number of columns to be displayed in the screen can be set for each sheet. The control unit 1 displays a setting screen 140 for designating a sheet name and size as shown in FIG. 9 according to a predetermined operation. The sheet input screen 100 can be set in three sizes: full size, half size (left), and half size (right). The full size is the maximum size, and FIG. 10 shows a display example. The half size (left) is the size of the left half of the full size, and allows the input contents of the basic screen 200 that is the background on the right side of the sheet input screen 100 to be seen. FIG. 11 shows a display example. For example, when the basic screen 200 is the chart 2 paper screen, the prescription information 220 on the right side is always visible, so the prescription data entered on the sheet input screen 100 is immediately reflected on the chart 2 screen and displayed. Will be confirmed. On the other hand, the half size (right) is the opposite, and the display example is shown in FIG.

  The number of columns displayed at a time on the sheet input screen 100 can be set between 1 and 8. This can also be set on a sheet basis. For example, when two columns are set, even if the screen size is full size, two columns are displayed, and even when the screen is half size, two columns are displayed. If the sheet has input items in the third and subsequent columns, a scroll bar is displayed at the lower end of the selection input unit, and can be displayed by scrolling left and right.

  A plurality of tabs can be set on the sheet input screen 100. This is shown in FIG. 13 and FIG. As shown in FIG. 13, the user first displays the sheet change screen 110, right-clicks in the footer portion thereof, and instructs to add a tab from the pull-down menu 118 (step S31; Yes). A tab name input screen 160 is displayed. Therefore, the user inputs an appropriate tab name and instructs the completion of setting. In response to this, the control unit 1 redisplays the sheet change screen 110 reflecting the setting contents. In the illustrated example, a tab with the name “Progress 5” is added. In the present embodiment, the number of tabs is not particularly limited. Each tab can have up to 8 columns. For example, in a sheet having five tabs, it is possible to use up to 40 columns of selection input units by switching the tabs. This tab can also be set for each sheet.

  Then, the setting items such as the input items and the size (size), the number of columns, and the tabs of the sheet input screen 100 as described above are recorded in the sheet file 11 on a sheet basis by the control unit 1 together with the sheet name data. (S34). At this time, the control unit 1 functions as a sheet setting unit.

  Next, a procedure for inputting patient medical data using the sheet set and registered in this way will be described with reference to the flowchart of FIG.

  The user who is mainly a doctor inputs the patient number of the patient from the keyboard 5 at the start of medical treatment, calls up the patient data, and displays it on the screen (step S1). Next, in order to display medical data of a patient who has already been registered, the second paper button on the right side of the screen is instructed. As a result, the past medical data is displayed in the same manner as the paper chart (S2). When it is desired to individually input data such as progress, prescription data, or disease name as in the past, the progress input button (S4), prescription input button (S6), and disease name input button (S8) on the right side of the screen, respectively. All you need to do is point. In response to this, the control unit 1 displays a progress input screen (S5), a prescription input screen (S7) or a disease name input screen (S9) which is an individual dedicated input screen.

  On the other hand, when a sheet input button peculiar to the present embodiment is instructed (S10: Yes), the control unit 1 reads out the data of the most recently used sheet among the sheets registered in the sheet file 11 in response thereto ( Same as S12) and displayed as a sheet input screen 100 (S13). At this time, the control unit 1 functions as a sheet display control unit. FIG. 5 shows an example of the display.

  Therefore, the user checks the necessary input items and inputs each data into the input field (S14). For example, “main complaint” in the upper left of the screen of FIG. 5 is checked, and the patient's complaint “there is sore throat from yesterday” is input from the keyboard 5. Also, the “body temperature” on the right side is checked, and the actual measurement value “38.6” is input. When necessary items are input in this way, the user instructs the OK button at the lower right of the screen. In response to this, the control unit 1 reflects and displays the data selected and input on the sheet input screen 100 on the chart No. 2 paper screen of the basic screen 200 and registers the data in the medical information file 15. It functions as a storage control means. Then, the sheet input screen 100 is closed. By using the sheet input screen 100 in this way, the patient's chief complaint, doctor's findings, vitals such as body temperature and blood pressure, drugs and prescriptions, and disease name data can be input on one screen.

  When a label is set on a sheet, if the label is set as a label for prescription data, the control unit 1 registers prescription data up to the next label as one prescription. As a result, if two or more prescriptions are divided and set on one sheet, a plurality of prescriptions can be registered with one input. As in the prior art, it is not necessary to repeat processing such as processing for displaying the prescription input screen and inputting and registering the first prescription data, and processing for inputting and registering the next prescription data.

  When the OK button is instructed on the sheet input screen 100 to return to the basic screen 200 and the chart 2 paper screen is displayed, the progress information 210 on the left side and the prescription information 220 on the right side are displayed in an easy-to-read manner. You can check what you have entered. If an input omission is found here, the sheet input button 100 may be displayed again by instructing the sheet input button.

  By the way, in the present embodiment, it is possible to reflect the data in the middle of input on the chart No. 2 screen without closing the sheet input screen 100. For this purpose, the user inputs in advance “continuous” to the left of the OK button on the sheet input screen 100, displays a check mark, and indicates the continuous input state. If this is checked, the control unit 1 reflects and displays the input items input when the OK button is instructed on the medical record No. 2 screen of the basic screen 200 and displays the data in the medical information file. 15 is registered. However, the sheet input screen 100 is not closed at this time. As a result, the user can continuously input on the open sheet input screen 100.

  Then, when the OK button is instructed, the control unit 1 reflects it on the No. 2 paper screen, and the input item registered in the medical information file 15 is changed to a italic character on the sheet input screen 100 so that it can be understood. To display it again. This prevents the user from knowing which items have already been registered, thereby preventing duplicate input and input omission. For example, when inputting data by scrolling the sheet input screen 100 to the left or right or switching tabs, the input data up to that point is registered before scrolling or before switching tabs. It is to do. It should be noted that any display mode can be used as long as it is easy for the user to understand, such as changing the color of the character, making it bold, or changing the color of the ground instead of italicizing the character.

It is a block diagram which shows the structure of the medical treatment assistance apparatus of embodiment. It is a flowchart which shows operation | movement of embodiment. It is a flowchart which shows operation | movement of embodiment. It is a figure which shows the structure of the sheet input screen of embodiment. It is a figure which shows the example of a display of the sheet input screen of embodiment. It is a figure which shows the example of a display of the sheet input screen of embodiment. It is a figure which shows the example of a display of the sheet change screen of embodiment. It is a figure which shows the example of a display of the sheet change screen of embodiment. It is a figure which shows the example of a display of the setting screen for designating the sheet size of embodiment. It is a figure which shows the example of a display of the sheet input screen of embodiment. It is a figure which shows the example of a display of the sheet input screen of embodiment. It is a figure which shows the example of a display of the sheet input screen of embodiment. It is a figure which shows the example of a display of the sheet change screen of embodiment. It is a figure which shows the example of a display of the tab name input screen of embodiment. It is a figure which shows the example of a display of the conventional disease name input screen.

Explanation of symbols

1 control device 2 CPU
3 Memory 4 Display Device 5 Keyboard 6 Mouse 7 File Device 11 Sheet File 12 Disease Name File 13 Treatment File 14 Patient File 15 Medical Information File 100 Sheet Input Screen 110 Sheet Change Screen

Claims (6)

A medical assistance device comprising an input means, a display means, and a storage means for inputting and registering patient medical information in a medical institution,
A medical information file that holds medical information of the patient and is stored in the storage means;
A sheet file that holds setting information of a sheet input screen for inputting medical information and is stored in the storage unit;
Display control means for reading setting information from a sheet file and displaying a sheet input screen on the display means;
Sheet setting means for setting input items such as treatment and prescription on the sheet input screen, and storing and controlling the setting information in the sheet file,
A selection input means for selecting and inputting a desired input item on the sheet input screen displayed on the display means;
Medical information storage control means for storing and controlling the input items selected and input on the sheet input screen in the medical information file of the patient,
The sheet setting means sets a plurality of tabs for each sheet according to an instruction, stores and controls the sheet file together with the name of each input tab,
The medical care support apparatus, wherein the selection input means selectively inputs input items by switching tabs displayed on a sheet input screen. The medical assistance device according to claim 1, wherein
The sheet setting means further separates the prescription separately from the input items on the sheet input screen according to an instruction, sets a label, and performs storage control.
The display control means displays a sheet input screen including the label,
The medical care information storage control means stores and controls the medical information file as a separate prescription for each label. In a medical support method of a medical support device comprising an input means, a display means, and a storage means, and inputting and registering patient medical information in a medical institution,
A sheet setting procedure for setting input items such as a user-desired treatment and prescription input by the input means on the sheet input screen and storing and controlling setting information in the storage means;
A display control procedure for reading setting information stored in the storage means and displaying a sheet input screen on the display means, and a selection input procedure for selecting and inputting a desired input item on the sheet input screen displayed on the display means And a sheet input control procedure consisting of a procedure for storing and controlling the input items selected and input on the sheet input screen as patient medical information in the storage means,
The sheet setting procedure sets a plurality of tabs for each sheet in accordance with an instruction, and stores and controls in the storage unit together with the names of the input tabs,
In the selection input procedure, the tab displayed on the sheet input screen is switched to selectively input an input item. In the medical treatment support method according to claim 3,
Further, the sheet setting procedure is for controlling the storage by setting the label and dividing the prescription separately from the input items on the sheet input screen according to the instruction,
The display control procedure displays a sheet input screen including the label,
The medical information storage control procedure stores and controls patient medical information as a separate prescription for each label. A program for a medical assistance device comprising an input means, a display means, and a storage means, for inputting and registering patient medical information in a medical institution,
A sheet setting procedure for setting input items such as a user-desired treatment and prescription input by the input means on the sheet input screen and storing and controlling setting information in the storage means;
A display control procedure for reading setting information stored in the storage means and displaying a sheet input screen on the display means, and a selection input procedure for selecting and inputting a desired input item on the sheet input screen displayed on the display means And a sheet input control procedure consisting of a procedure for storing and controlling the input items selected and input on the sheet input screen as patient medical information in the storage means,
The sheet setting procedure sets a plurality of tabs for each sheet in accordance with an instruction, and stores and controls in the storage unit together with the names of the input tabs,
In the selection input procedure, a medical support program for selecting and inputting input items by switching tabs displayed on a sheet input screen. In the medical treatment support program according to claim 5,
Further, the sheet setting procedure is for controlling the storage by setting the label and dividing the prescription separately from the input items on the sheet input screen according to the instruction,
The display control procedure displays a sheet input screen including the label,
The medical care information storage control procedure stores and controls patient medical information as a separate prescription for each label.

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