JP2012033095A - Document creation device for electronic medical chart - Google Patents

Abstract

PROBLEM TO BE SOLVED: To realize smooth medical services by allowing a plurality of medical staffs to open the same patient's electronic medical chart at the same time, and concurrently refer to, edit, create a variety of documents.SOLUTION: A document creation device for electronic medical charts includes: a patient's file for recording electronic data of the patient; a data base for storing the patient's files; and a plurality of terminals configured to be accessible to the data base. The patient's file includes a plurality of record areas, and each the record area is independently accessible and editable. And, each the record area is provided with an access control means which disables the access for editing from the other terminals when the record area is being accessed to be edited from one terminal.

Description

  The present invention relates to an electronic medical record document creation device, and more particularly, a plurality of medical staff can simultaneously open a patient's electronic medical record so that various documents can be referred to, edited, and created in parallel. The present invention relates to a document creation apparatus for an electronic medical record that realizes medical care.

With the expansion of computer utilization technology, medical institutions have been introducing electronic medical records using computers in place of paper medical records for the purpose of improving work efficiency and speed. Medical instructions such as medical records such as doctors and nursing records, as well as medical instructions, are issued by doctors as electronic documents including the date and time of execution and the contents of instructions to be executed. In order to clarify accountability, this electronic document is normally authenticated with a password, and the creator and creation date are recorded as non-editable data. Based on this medical instruction document, the medical staff performs a medical practice.
As techniques relating to such an electronic medical record, techniques disclosed in Patent Documents 1 to 3 are known.
JP 2008-225548 A JP 2009-146345 A JP 2003-16184 A

  The modern principle of team medicine is team medicine. Rehabilitation staff, registered dietitians, social workers, laboratory technicians, etc., as well as doctors and nurses, can form a team and provide comprehensive medical services to patients, providing highly effective and safe medical services. . In order for team medical care to function effectively, sharing information is a major premise. It is indispensable that you can immediately understand what each job type is thinking anywhere in the hospital and that you can create your own records at the same time without worrying about the usage status of other job types.

  However, the principle of information sharing and parallel work has not always been realized in conventional electronic medical records. Suppose someone opens a patient chart. When another staff member tries to open the electronic medical record of the same patient, a warning such as “This electronic medical record of the patient is already in use. It opens in the reference mode” is displayed. That is, the staff who opened the electronic medical record after the second can read (refer) the medical record, but cannot input (edit) orders and articles. When it came to a huge electronic medical record product, it was a specification that could not even be referenced. This is not much different from the paper medical record era, when the medical records were robbed between the staff.

  In recent years, supplements have been added to medical assistants as part of reducing the burden on working physicians. In some hospitals, it seems that trial introduction has started to reduce the work of electronic medical records for busy doctors by placing medical assistants in outpatient clinics. However, in the electronic medical chart lacking the simultaneous input function, the medical assistant cannot open the patient's medical chart in the edit mode while the doctor is examining. For this reason, note the doctor's instructions on paper, the doctor's medical examination for the patient is completed, the doctor closes the patient's electronic medical record, the medical record is opened again in edit mode, and the contents that were recorded Will be entered. Since the examination scene and the input scene are different from each other, there is almost no complicated and the accuracy of the input is lowered.

In an electronic medical record system lacking the simultaneous input function, if both the doctor's and nurse's PCs are online, there will always be medical records. In order to prevent this, there is a hospital where the notebook PC of the nurse is offline after copying the instruction data in the morning stage. At the end of work, the laptop is brought online, and the records during this period are written back to the server.
It is common for a patient's condition to change suddenly during the day, causing the doctor to give new instructions or change previous instructions. When the instruction is changed, the display of all the PCs is rewritten at that moment, and it is natural that the operation is continued based on the new instruction. However, even if there is a change in instructions, the change is not reflected on the notebook PC of the nurse who is offline, so the changed part is printed at the nurse station, and the doctor or ward chief is the nurse in the hospital room. I will run with the printed paper. If the instruction is changed in this way, a mistake 4 to 5 times the normal error occurs.

  The above situation is technically explained. Since electronic medical records handle enormous amounts of data, special software called database (Data Base Management System) that records, references, and searches data is used. The most used is RDB (Relational Data Base) which records data in a table format (Relation) and performs table operations in a standardized language called SQL (Systematic Query Language). The operation is performed in units of rows (records or tuples) in the table. In this case, if multiple records with different contents are written on the same line (when a record conflict occurs), all but one of them will disappear and the consistency of the contents of the entire database will be lost. End up. In extreme cases, the database itself will crash. In order to avoid this problem, in the database, the record lock function records all records that may be in conflict with each other so that they cannot be rewritten (locked). If a staff member opens a patient's chart, all records for this patient are locked to other staff members because this staff may edit. For this reason, other staff members are not able to perform any editing work at best, only by reference, until the staff member closes the patient's electronic medical record and all locks are released.

  The present invention has been made to solve such conventional problems, and an object of the present invention is to provide an electronic medical record document creation device that enables simultaneous and parallel editing and contributes to team medical care. is there.

  The electronic medical record document creation device according to claim 1 as means for achieving the object, a patient file in which electronic data relating to a patient is recorded, a database in which the patient file is stored, and a plurality of databases arranged to be accessible to the database An electronic medical record document creation device having an operation terminal, wherein the patient file has a plurality of record areas, and each record area can be accessed and edited independently, Access control means for disabling access for editing from other operation terminals when receiving access for editing from the other operation terminal is provided.

  The electronic medical record document creation device according to claim 2, wherein the electronic medical record document creation device has a function of confirming access authority to the record area from the operation terminal, It is characterized in that at least one of the flag display functions for displaying that the access state is intended for editing is provided.

  In the electronic medical record document creation device according to claim 3, in the electronic medical record document creation device according to any one of claims 1 to 2, editing of the record area is performed after a predetermined time has elapsed since the completion of editing of each record area. A time-limited editing restricting means for disabling is provided.

  5. The electronic medical record document creation apparatus according to claim 4, wherein each of the record areas has a record area that is serially connected to a lower level. Further, the present invention is characterized in that an edit restriction means based on an existing document is provided that disables editing a record area where a record area exists.

  In the electronic medical record document creation apparatus according to claim 5, in the electronic medical record document creation apparatus according to claim 4, the editing restriction means based on the existing document is released by deleting the record area connected to the lower part of the record area. The record area can be edited.

In this invention, since the said structure is employ | adopted, it has the following effects.
The electronic medical record document creation apparatus according to claim 1, wherein the patient file has a plurality of record areas, and each record area can be accessed and edited independently. Can be entered, and an appropriate description format according to the purpose is realized.
Each record area has access restriction means that disables access from other operation terminals when access is received from any operation terminal. can do. For this reason, conventionally, access restriction is applied to the entire personal file. However, access restriction is performed on a part of record basis, and other staff members can edit other record areas even for the same patient.

The electronic medical record document creation apparatus according to claim 2 has a function of confirming the access authority to the record area from the operation terminal, so that smooth access is ensured by eliminating erroneous access and unnecessary access. .
In addition, since a flag display function for displaying the access state is provided, when another staff member wants to access, it can be confirmed on the display that the access is in progress.

  The electronic medical record document creation apparatus according to claim 3 is provided with time-limited editing restriction means for disabling editing of a record area after a predetermined time has elapsed since completion of editing of each record area. It is possible to prevent contact mistakes due to rewriting of medical records and tampering of medical records.

In the electronic medical record document creation apparatus according to the fourth aspect of the present invention, each record area has a record area that is serially connected to the lower order, so that the record areas are displayed in a time series or in the order of description.
And, since the record area where the record area exists at the lower level is provided with the editing restriction means by the existing document that cannot be edited, the instruction document located at the upper level is not suddenly changed, and the instruction report system Prevent complications.

  In the electronic medical record document creation apparatus according to claim 5, by deleting the record area connected to the lower part of the record area, the editing restriction means by the existing document is released and the record area can be edited. Editing is possible after obtaining the consent of the record area's reporter.

The best mode for carrying out the present invention will be described.
As shown in FIG. 1, the electronic medical record document creation apparatus of the present invention is composed of a server that executes a specific process and a client that receives a service from the server. Are provided with an input device, a control device, a memory device and an external storage device.
Since a plurality of computers are connected on the network, the medical instruction from the doctor to the medical staff and the treatment report from the medical staff to the doctor are made through this system.
Medical data (patient files) related to patients are recorded in the database of the server. Access to this database from operation terminals installed at various locations in medical facilities allows viewing, editing, updating, and recording of patient files. It has become.

Hereinafter, specific examples of the present invention will be described.
FIG. 2 shows a conceptual diagram of conflict prevention using a document record editability flag. Fig. 2 (a) shows that when a patient's chart is opened in the conventional way of preventing competition, an edit prohibition flag is set on all document records related to the patient, and simultaneous editing by another staff is prohibited. Yes. For this reason, the situation where team medical care became difficult as mentioned above had arisen.
In FIG. 2A, (1) indicating that the staff of the medical facility is accessing is displayed in the edit prohibition column of the patient (Ichiro Yamashita). This prevents other staff from accessing and editing this patient file.

  In contrast, FIG. 2B is a conceptual diagram according to the present invention. When a certain document of a certain patient is opened in the edit mode, an edit prohibition flag is set only for the document (record area), not the entire patient file. Thus, other documents for the patient are still open to other staff as editable. Thereby, for example, when a doctor is editing a doctor article document, the nurse can simultaneously edit the patient's nursing record document in parallel. When editing is completed, the editing contents of the document are updated and the edit prohibition flag is canceled. In this figure, an example is shown in which only one document is edited. However, a plurality of documents such as a doctor article document and an Xp instruction document may be simultaneously edited as necessary.

In FIG. 2 (b), (1) is displayed where the staff is accessing one place of the edit prohibition column of the patient (Ichiro Yamashita), but (0) is displayed and accessed in the other record area. Is in an editable state.
In this embodiment, the patient file has a plurality of record areas, and each record area can be accessed and edited independently. When each record area is accessed from any of the operation terminals, Access restriction means for disabling access from other operation terminals is provided. The program realizing the access restriction means displays a flag (1) in the edit prohibition column.
The access restriction means permits browsing of data in the record area constituting the patient file and prohibits access in the edit mode, but it is also possible to prohibit access to the data itself.

In FIG. 2, the patient name, document type, etc. are recorded in one table for convenience. In an actual relational database, a patient name master and a document type master are prepared separately, only the ID numbers of each are described, and the original table is restored by performing a join operation with those master tables. There is no.
That is, the record area is distributed and recorded in a plurality of folders in the database, but if a patient-specific identification code is searched, a patient file that displays medical data related to the patient is generated.

  Since the editability flag serves its purpose if it is logically expressed in the restored original table (patient file), the physical record of the editability flag itself may be present in the related table. In FIG. 2, the table includes various document types. However, depending on the electronic medical record, an individual table is assigned to each document type. In this case as well, the problem of whether the editability flag is set on the entire document record of the patient or an individual document is the same.

There are also edit prohibition means that are not physically specified, such as an editability flag. In FIG. 2, medical instructions such as Xp instructions and medication support notes are exclusive matters of doctors, and even if a staff other than the doctor's occupation tries to edit these instructions, the creation and editing of the type document is not possible. Reject. In this way, if there is an editor permission determining means for determining creation authority and editing authority for the type document, doctors and nurses can not compete for creation and editing of the same document. Parallel input is possible.
In other words, access congestion can be prevented by setting a function to confirm access authority that allows access only to doctors or qualified staff according to the characteristics of each record area attached to access restriction means. Thus, the patient file can be edited smoothly. This is possible by constructing an authentication mechanism such as a password according to the qualification.

Further, if there is a means for determining whether or not editing is possible based on the elapsed time, it is considered that the medical record is falsified for a re-editing request after a certain time has passed since the last editing time of the document. The amount of documents that can compete is drastically reduced. For example, document editing after the next day may be rejected regardless of job type.
For example, when a time recognition function for storing the edit time is added to the record area, the time at which the written data is confirmed and saved is recorded, and access is received in the edit mode, a predetermined time compared to the server timer Accepts access or rewrite, but adopts a method of rejecting access or rewrite after a predetermined time.

  As described above, the electronic medical record document creation apparatus according to the first embodiment determines whether or not editing is possible for each document based on at least one of the attribute values recorded in the electronic medical record document itself or the related record. Even if multiple staff members open the same patient's electronic medical record, it is possible to prevent conflicts in editing the same document, thereby enabling simultaneous input that is indispensable for team medical care.

  FIG. 3 is an explanatory diagram of the document edit prohibition means (edit restriction means based on existing documents) based on the presence of related documents according to the second embodiment. FIG. 3A shows a relationship between related document groups such as a blood test instruction by a doctor as an example, a blood collection execution report by a nurse, a test specimen reception report by a clinical laboratory technician, and a test result report. FIG. 3B to FIG. 3E are document examples of instruction sheets and various implementation reports.

  The doctor issues a blood test instruction for a patient based on his / her authority (FIG. 3B). Immediately after the instruction is issued, the contents can still be changed by the doctor. In response to the instruction, the nurse collects blood from the patient and creates a blood collection report (FIG. 3C). When this blood collection report is created, editing of blood test instructions is prohibited. This is because if the instruction sheet that has already been implemented is changed, consistency between the instruction and the contents of the implementation cannot be obtained, which may cause a medical accident. Thereafter, a specimen reception report (FIG. 3 (d)) and a result report (FIG. 3 (e)) are created by the clinical laboratory technician in sequence, and the work for responding to the instruction is completed. In this way, it is possible to prevent the work between staff members from being confused due to competing instructions with different contents due to the time difference, by means of the edit refusal means that has already been implemented, which prohibits the editing of the instructions on which the implementation report document has been created I can do it.

If multiple doctors are involved in the treatment of the same patient, another doctor may edit and change the instructions issued by one doctor while the doctor does not know. This is also a source of confusion. In order to prevent this situation, the doctor who created the instruction form creates a dummy refusal declaration document, which is a dummy implementation report, and rejects edits and changes made by other doctors. Can be used.
In the event that it is necessary to change the instruction content after the implementation, it is possible to edit and change only after the related document group is deleted from the end and only the original instruction document is obtained. In the sequential deletion from the end of this related document, if only the creator of the implementation report document has the authority to delete it, all parties concerned will be informed that the instruction content has been changed, so confusion among staff will be Prevented and helps reduce medical accidents.

  3 will be described in more detail. In the blood test instruction sheet shown in FIG. 3B, a doctor (Tetsuo Kinoshita) issues a blood test instruction to the patient (Kazuo Yamada). In the blood collection report shown in FIG. 3 (c), an implementation report “The blood collection has been completed.” Is made following the description in (b). In FIG. 3 (d), following the description in (c), a receipt report “Specimen received” is made by a clinical laboratory technician. In FIG. 3 (e), “Result report has been prepared” is reported following (d). These instructions and reports are entered in the record area and recorded on the server.

In this way, the doctor's instruction sheet or the input data of a staff member having a specific access right is located in the uppermost record area, and subsequently, the record areas such as the implementation report and the communication are serially connected in the lower order. The electronic medical record document creation apparatus has a determination program for determining whether or not a lower-level record area exists. If the determination program recognizes the existence of the lower-level document, the record area cannot be edited. .
Therefore, when the description content of the record area is corrected, the lower record area must be erased and re-edited. When deleting a lower record area, an input person of each record area inputs a deletion password or the like and sequentially deletes it, so that the intention of deletion is surely shared with the creator of the lower record area.

In the electronic medical record document creation apparatus according to the present embodiment, as in the first embodiment, the patient file has a plurality of record areas, and the record areas can be independently accessed and edited. Is provided with an access restriction means for disabling access for editing from other operation terminals when receiving access for editing from any of the operation terminals.
At least one of a function for confirming the access authority to the record area from the operation terminal and a flag display function for displaying that the access state is intended for editing is provided.
In addition, as in the first embodiment, it is also possible to arrange time-limited editing restriction means for disabling editing of a record area after a certain period of time has elapsed since completion of editing of each record area. In this case, in this embodiment, both the editing restriction means based on the existing document and the time-limited editing restriction means are arranged side by side, but the editing restriction means based on the existing document is canceled only within the time allowed by the time-limited editing restriction means. Both of them can be juxtaposed by setting such that the record area can be re-edited.

  The present invention may be completed on a single computer in a personal clinic or the like. Usually, a data management computer called a server computer and a plurality of client computers scattered in the field are connected by a network called a LAN. Offered in form. In the future, the form of using virtual server computers built on the Internet via the Internet browser, such as SaaS or cloud, will increase.

  Although the embodiments have been described above, the specific configuration of the present invention is not limited to the above-described embodiments, and design changes and the like within a scope not departing from the gist of the invention are included in the present invention.

It is a schematic explanatory drawing of the network to which the electronic medical record document preparation apparatus is applied. It is explanatory drawing of the document preparation apparatus of the electronic medical record which concerns on 1st Example. (A) It is explanatory drawing which shows the relationship of a record area | region. (B) It is explanatory drawing of the record area | region of a blood test instruction sheet. (C) It is explanatory drawing of the record area | region of a blood collection implementation report. (D) It is explanatory drawing of the record area | region of a sample receipt report. (E) It is explanatory drawing of the record area | region of a result report.

Claims (5)

A patient file in which electronic data related to a patient is recorded, a database in which the patient file is stored, and an electronic medical record document creation device including a plurality of operation terminals arranged to be accessible to the database,
The patient file has a plurality of record areas, and the record areas can be independently accessed and edited,
Each record area is provided with an access restriction means for disabling access for editing from other operation terminals when receiving access for editing from any of the operation terminals. An electronic medical record document creation device.   The electronic medical record document creation device has at least one of a function for confirming access authority to the record area from the operation terminal and a flag display function for displaying that the access state is intended for editing. The electronic medical record document creation apparatus according to claim 1, wherein   3. The electronic medical record according to claim 1, further comprising a time-limited editing restricting means for disabling editing of the record area after a predetermined time has elapsed since completion of editing of each record area. Document creation device.   Each of the record areas has a record area that is serially connected to a lower level, and the record area having a lower level record area is provided with an edit restriction unit based on an existing document that disables editing. The electronic medical record document creation apparatus according to claim 1.   5. The electronic medical record document creation apparatus according to claim 4, wherein the record area can be edited by canceling the editing restriction means based on the existing document by erasing the record area connected to the lower part of the record area.

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