JP2018139156A - Medical record creation support system, server device, medical institution terminal, medical record creation support method, medical institution device, and medical record creation support program - Google Patents

Abstract

PROBLEM TO BE SOLVED: To provide a medical record creation support system that resolves complexity of operability, and reduces a burden on a doctor and a medical institution in inputting data for creating a medical record.SOLUTION: In a medical record creation support system of the present invention, a medical institution terminal comprises: region information receiving means that receives information on a region forming the body according to a user's input operation; symptom specification information transmission means that transmits information on specification of a symptom; symptom candidate receiving means that receives candidates for the symptom; symptom selection receiving means that receives selection of a symptom from the received candidates for the symptom according to the user's input operation; and progress information receiving means that receives progress information on a chief complaint according to the user's input operation, and a server device comprises: symptom specification information receiving means that receives the symptom specification information; symptom candidate extraction means that extracts symptoms corresponding to the received region as candidates for symptom; and symptom candidate transmission means that transmits the extracted candidates for the symptom.SELECTED DRAWING: Figure 1

Description

  The present invention relates to a medical record creation support system having an interface for enabling a medical staff to easily create a medical record by inputting information in a drawing during medical treatment.

  Recently, in medical institutions, electronic medical records are being introduced for the purpose of saving paper medical record storage space or performing medical work efficiently. However, when a doctor who is not used to operating a personal computer or the like inputs an electronic medical record, it may be a burden on the doctor or the like due to a problem that the input takes time. At the time of medical care, the contents written on the paper chart by the medical staff are often the minimum and very simple contents, but the electronic chart has many required input items and is cumbersome and time consuming. For this reason, there are hospitals and the like in which an electronic medical record input person is prepared separately. In order to solve such a problem, for example, an electronic medical record for setting input items such as treatment and prescription desired by a user on a sheet input screen is disclosed for the purpose of simplifying input to the electronic medical record. (For example, refer to Patent Document 1).

  Incidentally, electronic medical records have been proposed that have not only the aspect of replacing the description on paper with the input of electronic data, but also the aspect of supporting medical care by a doctor or the like. For example, for the purpose of performing a treatment suitable for a patient's medical condition without being influenced by the experience of a doctor or the like, a database in which patient's medical condition information is associated with disease information related to a disease corresponding to the medical condition information A diagnosis support apparatus is disclosed that identifies disease information corresponding to this disease state information when the patient's disease state information is input in advance (see, for example, Patent Document 2).

  In addition, there is an electronic medical record system that uses a schema for inputting a complaint. However, there are many tasks that users have to create electronic medical record data, such as switching between screens and selecting a schema that matches the patient's chief complaint. It was. Therefore, in order to reduce the burden of user input, we have a management file that associates the name of each part of the body with a schema diagram, and if you enter a phrase related to the patient's chief complaint, refer to the management file and change the phrase A medical assistance device that displays related schema diagram candidates is disclosed (for example, see Patent Document 3).

JP 2009-9609 A JP 2009-59381 A Japanese Patent Laid-Open No. 11-312202

  By the way, when a doctor or the like inputs a chief complaint in an electronic medical chart at the time of medical care, it is necessary to input an affected part, a symptom (for example, rash, numbness, etc.) in the affected part, and a course after the symptom appears. However, in the methods described in these patent documents, it is necessary to input information on these main complaints with a keyboard or to select from a large number of options. It was not something that could be done. The present invention has been made to solve such problems, and mainly solves the complexity of operability and reduces the burden of data input for creating medical records for doctors and medical institutions. The purpose is to provide a record creation support system.

  The present invention is a medical record creation support system including a medical institution terminal in which a user can input a medical record, and a server device capable of communication connection with the medical institution terminal, wherein the medical institution terminal is a user In response to the input operation, part information receiving means for receiving information about the part constituting the living body, and symptom specifying information transmitting means for transmitting information about the part received by the part information receiving means to the server device as symptom specifying information; A symptom candidate receiving means for receiving a symptom candidate transmitted from the server device, a symptom selection receiving means for receiving a symptom selection from the symptom candidate received by the symptom candidate receiving means in response to a user input operation, and a user In response to the input operation, the progress information receiving means for receiving progress information on the progress of the symptom, the symptom selected by the symptom selection receiving means, and the A main complaint information display means for displaying the progress information received by the information accepting means on the display device as main complaint information, and the server device associates a part constituting the living body with a symptom that may develop in the part. Included in the part information received by the part information receiving means from the symptoms stored in the symptom candidate storing means, the symptom specifying information receiving means for receiving the symptom specifying information transmitted from the medical institution terminal, and the symptoms stored in the symptom candidate storing means A symptom candidate extraction means for extracting a symptom corresponding to a region to be treated as a symptom candidate, and a symptom candidate transmission means for transmitting the symptom candidate extracted by the symptom candidate extraction means to a medical institution terminal, and a medical institution terminal or server The present invention relates to a medical record creation support system provided with a main complaint information storage means for storing main complaint information.

  The medical record creation support system according to the present invention can create a medical record by performing a simple input operation when, for example, a medical worker such as a doctor, a dentist, or a veterinarian treats a patient or an animal. It can be done. Furthermore, by designing to extract symptom candidates according to the site, symptom candidates that can develop in the affected area can be provided as options. As a result, since selectable symptoms are narrowed down, it is possible to reduce a burden for a medical worker or the like to input the symptoms.

  In the present invention, the main complaint information storage means stores other main complaint information about a part different from the part, the symptom specifying information includes other main complaint information stored in the main complaint information storage means, and a server The apparatus includes a disease candidate storage unit that stores a symptom and a disease candidate that can be identified from the symptom in association with each other, and a disease stored in the disease candidate storage unit, and is included in other main complaint information stored in the main complaint information storage unit A first disease candidate extraction means for extracting a disease corresponding to a symptom as a disease candidate, wherein the symptom candidate extraction means is a symptom corresponding to a site included in the symptom specification information received by the symptom specification information reception means. In the disease candidate storage unit, it is preferable to extract a symptom corresponding to the disease candidate extracted by the first disease candidate extraction unit.

  The medical record creation support system of the present invention further limits the symptom options that can be input for the newly input site in accordance with the main complaint information regarding the other site that has already been input. For example, if information about the main complaint such as symptoms and progress has already been input for other sites, candidate diseases that the patient may be affected are extracted from the sites and symptoms included in the main complaint information. A symptom group that can develop in a site where a new input is performed is extracted. By designing in this way, it is possible to provide symptom groups related to diseases that are likely to be affected by patients to medical professionals as options, making it easier to input symptoms, Providing accurate medical care.

  In the present invention, the medical institution terminal includes a drawing display unit that displays a drawing related to the appearance or inside of a living body on a display device, and the part information receiving unit is displayed on the drawing display unit in response to a user's input operation. It is preferable to accept selection of parts in the drawings.

  The medical record creation support system of the present invention can specify a site related to a patient's chief complaint when a medical worker or the like performs an input operation on a drawing (for example, a schema diagram). By designing in this way, a medical worker or the like can input by a simple operation such as clicking with a mouse or the like without performing troublesome character input, and the convenience of the system can be improved.

  In the present invention, the part information receiving means specifies a point corresponding to the affected area of the patient in the drawing displayed on the drawing display means in accordance with a user's input operation, and according to the specified point, The selection is accepted, and the main complaint information display storage means preferably displays the main complaint information in association with the specified point.

  In the medical record creation support system of the present invention, the points or areas specified by the medical staff or the like in the drawing, and information on the symptoms, initial period, and progress of the main complaint are displayed. By designing in this way, a medical worker can visually and efficiently grasp the affected part, symptom, and progress information that are information related to the main complaint. Since screen transition is unnecessary, medical treatment can be performed efficiently.

  In the present invention, it is preferable that the progress information received by the progress information receiving means includes main complaint start information regarding the start of the main complaint and main complaint progress information regarding the history of changes in symptoms of the main complaint.

  In medical care of medical staff, as prescribed in Article 24, Paragraph 1 of the Medical Doctor Law, it is obliged to “record progress” without delay after treating a patient. In the medical record creation support system according to the present invention, information that is essentially unnecessary in medical practice, such as information necessary for calculating medical fees, is omitted, and the symptoms, initial period, and progress related to the main complaint are omitted. Information is the minimum information necessary for medical care. With such a design, it is possible to suppress an increase in the burden on medical staff and the like.

  In this invention, it is preferable that a medical institution terminal is provided with the drawing means which draws a point or a line on the drawing displayed by the drawing display means according to a user's input operation.

  The medical record creation support system of the present invention can freely write a memo on a drawing or the like displayed on a display screen by touching a pointer device such as a mouse or a touch panel. By designing in this way, medical staff and the like can write notes with the same feeling as described on a paper chart, and can use abbreviations and the like uniquely used by medical staff. As a result, medical staff and the like can create medical record data in a format that makes it easy to grasp the contents, and can efficiently input information and grasp information in medical treatment.

  The present invention relates to a main complaint information transmitting means for a medical institution terminal to transmit main complaint information including a symptom selected by a symptom selection accepting means to a server device, and a disease candidate receiving means for receiving a disease candidate transmitted from the server device. The disease candidate display means for displaying the disease candidate received by the disease candidate reception means on the medical institution terminal, and the disease as a result of diagnosis from the disease candidate displayed by the disease candidate display means according to the user's input operation A disease accepting means for accepting the selection of the disease, and the server device stores the disease candidate storage means for associating and storing the symptom and the disease candidate that can be identified from the symptom, and the main complaint for receiving the main complaint information transmitted from the medical institution terminal The disease corresponding to the symptom included in the main complaint information received by the main complaint information receiving means from the disease stored in the information receiving means and the disease candidate storage means A second disease candidate extraction means for extracting as a disease candidates extracted by the second disease candidate extracting means preferably includes a disease candidate transmission means for transmitting to the medical institution terminal.

  The medical record creation support system of the present invention can extract related diseases based on the affected part related to the main complaint and information on symptoms in the affected part. By designing in this way, even if doctors do not refer to specialized books etc., it is possible to narrow down the candidates for diseases that may be affected by the patient, and the number of diseases that medical professionals etc. consider Thus, it is possible not only to reduce medical care and enable efficient medical care, but also to prevent erroneous diagnosis.

  In addition, by constantly updating the information on the disease candidates stored in the storage device of the server device, medical staff at the medical site can perform medical care using the latest medical information. As a result, it becomes possible to examine diseases that the health care professionals did not have as knowledge, and it has the effect of improving the quality and safety of medical practice such as prevention of misdiagnosis as well as efficiency of medical care.

  The present invention is a server device capable of communication connection to a medical institution terminal through which a user can input a medical record, by associating a part constituting a living body with a symptom that can develop in the part. Symptom specification information received by the symptom specification information receiving means from the symptoms stored in the symptom candidate storage means, and symptom specification information receiving means for receiving symptom specification information transmitted from the medical institution terminal The present invention relates to a server apparatus including a symptom candidate extraction unit that extracts a symptom corresponding to a site included in a symptom candidate, and a symptom candidate transmission unit that transmits a symptom candidate extracted by the symptom candidate extraction unit to a medical institution terminal.

  The present invention is a medical institution terminal in which a user can input a medical record, which can be connected to a server device by communication, and receives information related to a part constituting a living body according to a user's input operation Symptom specification information transmitting means for transmitting information about the part received by the receiving means, part selection receiving means to the server device as symptom specifying information, symptom candidate receiving means for receiving the symptom candidate transmitted from the server device, A symptom selection accepting unit that accepts a symptom selection from symptom candidates received by a symptom candidate receiving unit according to a user's input operation, and a progress information accepting unit that accepts progress information related to a chief complaint according to a user's input operation And the symptom selected by the symptom selection receiving means and the progress information received by the progress information receiving means on the display device as main complaint information That relates to a medical institution terminal and a chief complaint information display means.

  The present invention is a medical institution terminal in which a user can input a medical record, and a medical record creation support method executed in a server device that can be connected to the medical institution terminal by communication, in the medical institution terminal, A step of receiving information on a part constituting the living body in response to an input operation to the input unit of the user, and a step of transmitting information on the accepted part to the server device as symptom specifying information via the communication interface unit Receiving a symptom candidate transmitted from the server device via the communication interface unit, receiving a symptom selection from the received symptom candidate according to an input operation to the input unit of the user, and using Accepting the progress information related to the chief complaint in response to an input operation to the input unit of the person and accepting the selection of symptoms on the display device The step selected to display the symptom selected in the step and the progress information received in the step of receiving the progress information as main complaint information, and the symptom specifying information transmitted from the medical institution terminal via the communication interface unit in the server device And in the symptom specifying information received from the medical institution terminal from the symptom stored in association with the part constituting the living body in the storage device and the symptom that can develop in the part in the control unit The present invention relates to a medical record creation support method comprising a step of extracting a symptom corresponding to a part as a symptom candidate and a step of transmitting the extracted symptom candidate to a medical institution terminal via a communication interface unit.

  The present invention is a medical institution apparatus in which a user can input a medical record, a symptom candidate storage unit that stores a part of a living body in association with a symptom that can develop in the part, and a user's In response to an input operation, a part information receiving unit that receives information on a part constituting the living body and a symptom corresponding to the part received by the part selection receiving unit are extracted as symptom candidates from the symptoms stored in the symptom candidate storage unit. A symptom candidate extracting means, a symptom selection receiving means for receiving a symptom selection from the symptom candidates extracted by the symptom candidate extracting means according to a user's input operation, and a progress relating to the main complaint according to the user's input operation The progress information receiving means for receiving information, the symptom selected by the symptom selection receiving means, and the progress information received by the progress information receiving means are displayed on the display device as main complaint information. A chief complaint information display means for, to a medical institution system and a chief complaint information storage means for storing chief complaint information into the storage unit.

  The present invention is a medical record creation support program executed in a medical institution apparatus in which a user can input a medical record, the medical institution apparatus, a part constituting a living body, and a symptom that can develop in the part Symptom candidate storage means for storing information in association with each other, part selection receiving means for receiving information on a part constituting the living body in response to a user's input operation, and part selection receiving means from symptoms stored in the symptom candidate storage means A symptom candidate extraction unit that extracts a symptom corresponding to the site received by the symptom candidate, and a symptom selection reception unit that receives a symptom selection from the symptom candidate extracted by the symptom candidate extraction unit according to a user input operation; The progress information receiving means for receiving the progress information related to the chief complaint, the symptom selected by the symptom selection receiving means, and the progress information receiving according to the user's input operation The progress information received by the means, the chief complaint information display means for displaying on the display device as the chief complaint information relates to the medical record creation support program for causing to function as the chief complaint information storage means for storing a chief complaint information into the storage device.

It is an example of the block diagram which shows the structure of the medical record preparation assistance system concerning embodiment of this invention. It is an example of the block diagram for demonstrating the function of the medical institution terminal concerning embodiment of this invention. It is an example of the block diagram for demonstrating the function of the server apparatus concerning embodiment of this invention. It is a figure which shows an example of the patient information database concerning embodiment of this invention. It is a figure which shows an example of the electronic medical record database concerning embodiment of this invention. It is a figure which shows an example of the template selection screen of the schema diagram concerning embodiment of this invention. It is a figure showing the interface of the medical institution terminal at the time of registering the main complaint concerning embodiment of this invention. It is a figure which shows an example of the flowchart of the main complaint information registration process concerning embodiment of this invention. It is a figure which shows an example of the symptom and disease candidate database and essential symptom database concerning embodiment of this invention. It is a figure which shows an example of the selection result of the symptom which concerns on the chief complaint in the schematic diagram concerning embodiment of this invention. It is a figure which shows an example of selection or the input screen of the main complaint progress information in the schematic diagram concerning embodiment of this invention. It is a figure which shows an example of the main complaint information database concerning embodiment of this invention. It is a figure which shows an example of the disease candidate list extraction process concerning embodiment of this invention. It is a figure which shows an example of the screen which registered the several main complaint in embodiment of this invention. It is a figure which shows an example of the main complaint information registration process in the medical institution apparatus concerning embodiment of this invention. It is a figure which shows an example of the flowchart of the main complaint information registration process in the case of extracting the symptom candidate list concerning embodiment of this invention in consideration of the existing main complaint information. It is a figure which shows an example of the flowchart of a symptom candidate list process in the case of extracting the symptom candidate list concerning embodiment of this invention in consideration of the existing main complaint information.

  Hereinafter, embodiments of the present invention will be described. However, the present invention is not limited to the embodiments described in the embodiments unless contrary to the gist of the present invention. FIG. 1 is an example of a block diagram showing a configuration of a medical record creation support system according to an embodiment of the present invention. As illustrated, the medical record creation support system includes a server device 1, a communication network 2, and a plurality of medical institution terminals 3. It is preferable that at least one medical institution terminal 3 is provided for each medical institution in which the medical record creation support system of the present invention is introduced.

  The server device 1 includes a control unit 11, a RAM (Random Access Memory) 12, a hard disk drive (HDD) 13, and a communication interface 14, which are connected by an internal bus. The communication interface 14 is connected to a medical institution terminal 3 to be described later via the communication network 2.

  The control unit 11 includes a CPU (Central Processing Unit) and a ROM (Read Only Memory). The control unit 11 executes a program stored in the HDD 13 and controls the server device 1. The RAM 12 is a work area for the control unit 11. The HDD 13 is a storage area for storing programs and data. Programs and data necessary for the execution of the medical record creation support system are read from the HDD 13 and loaded into the RAM 12.

  The control unit 11 reads out programs and data necessary for executing various processes in the medical record creation support system from the RAM 12 and performs the processes. The control unit 11 processes the program and data loaded in the RAM 12 to generate data to be transmitted to the medical institution terminal 3 and transmits the data from the communication interface 14 via the communication network 2. Moreover, the data which the communication interface 14 received from the medical institution terminal 3 and the data which the control part 11 processed are memorize | stored in a memory | storage device as needed.

  The communication interface 14 transmits and receives information by connecting to the communication interface 36 of the medical institution terminal 3 via the communication network 2.

  As long as the communication network 2 can connect the server device 1 and the medical institution terminal 3, any network such as the Internet or a dedicated line may be used. From the viewpoint of maintaining confidentiality of information transmitted and received, the VPN A communication network using a communication method capable of preventing information leakage to a third party such as connection is preferable.

  The medical institution terminal 3 includes a control unit 31, a RAM (Random Access Memory) 32, a hard disk drive (HDD) 33, an input device 34, a display device 35, and a communication interface 36, which are connected by an internal bus. The display device 35 is provided with a display screen 35a.

  The control unit 31 includes a CPU (Central Processing Unit) and a ROM (Read Only Memory). The control unit 31 executes a program stored in the HDD 33 and controls the medical institution terminal 3. The RAM 32 is a work area for the control unit 31. The HDD 33 is a storage area for storing programs and data. Programs and data necessary for executing various processes in the medical institution terminal 3 are read from the HDD 33, the communication interface 36 that receives data from the server device 1 via the communication network 2, the input device 34, and the like, and loaded into the RAM 32. The

  The control unit 31 reads programs and data necessary for executing various processes in the medical institution terminal 3 from the RAM 32 and performs the processes. The control unit 31 processes the program and data loaded in the RAM 32 to generate data to be transmitted to the server device 1 and transmits the data from the communication interface 36 via the communication network 2.

  The input device 34 includes an input device such as a mouse, a keyboard, a touch panel, and the like, and accepts operation inputs and information inputs from medical personnel who are users.

  The display device 35 includes a display screen 35a for displaying information viewed by the user. A plurality of display screens 35a of the medical institution terminal 3 may be provided. The data processed by the control unit 31 is displayed on the display screen 35a of the display device 35 as necessary.

  The communication interface 36 transmits and receives information by connecting to the communication interface 14 of the server device 1 via the communication network 2.

  FIG. 2 is an example of a block diagram for explaining functions of the medical institution terminal according to the embodiment of the present invention. The medical institution terminal 3 in the present invention includes a part information reception function 41, a symptom identification information transmission function 42, a symptom candidate reception function 43, a symptom selection reception function 44, a progress information reception function 45, a main complaint information display function 46, and a drawing display function 47. A drawing function 48, a main complaint information transmission function 49, a disease candidate reception function 50, a disease candidate display function 51, and a disease reception function 52. The control unit 31 controls the execution of these functions.

  FIG. 3 is an example of a block diagram for explaining the function of the server device according to the embodiment of the present invention. The server device 1 in the present invention includes a symptom specifying information receiving function 61, a symptom candidate extracting function 62, a symptom candidate transmitting function 63, a first disease candidate extracting function 64, a main complaint information receiving function 65, a second disease candidate extracting function 66, and a disease. A candidate transmission function 67 is provided. The control unit 11 controls the execution of these functions.

  The symptom specifying information transmission function 42 of the medical institution terminal 3 has a function of transmitting information specifying the symptom related to the main complaint to the server device 1. The main complaint information transmission function 49 has a function of transmitting information related to the main complaint to the server device 1. The symptom candidate reception function 43 has a function of receiving a symptom candidate list from the server device 1. The disease candidate reception function 50 has a function of receiving a disease candidate list from the server device 1. The information described here will be described later.

  The symptom specifying information receiving function 61 of the server device 1 has a function of receiving information for specifying symptoms related to the main complaint from the medical institution terminal 3. The main complaint information receiving function 65 has a function of receiving information related to the main complaint from the medical institution terminal 3. The symptom candidate transmission function 63 has a function of transmitting a symptom candidate list to the medical institution terminal 3. The disease candidate transmission function 67 has a function of transmitting a disease candidate list to the medical institution terminal 3. The information described here will be described later.

  When the medical record creation support system is activated at the medical institution terminal 3, the medical institution terminal 3 accesses the server device 1. At this time, in order to identify a terminal or a medical institution, login may be performed using an account and a password.

  Then, the premise of implementation of this invention is demonstrated. FIG. 4 is a diagram showing an example of a patient information database according to the embodiment of the present invention. In the patient information database 70 provided in the server device 1, a name 72, a gender 73, a date of birth 74, an address 75, an insurance card number 76 and the like are stored in association with the patient ID 71. When using the system of the present invention, it is necessary to register patient information. This is because the information related to the electronic medical record is associated with one medical record information for each patient.

  FIG. 5 is a diagram showing an example of an electronic medical record database according to the embodiment of the present invention. The electronic medical record NO81 stores a patient ID 82, a visit date and time 83, a schema diagram NO84, a template 85, a chief complaint NO86, and the like. The electronic medical record NO81 basically corresponds to the patient ID 82. The visit date and time 83 is the date when a medical worker or the like performed medical care for a patient, and the system date when the electronic medical record data was registered is registered.

  The schema diagram NO84 is a number indicating the schema diagram registered in the medical practice. If there are a plurality of chief complaints in one medical treatment and each of them is an unrelated medical condition, etc. A schema diagram may be registered. For example, a patient who visits a general hospital visits an ophthalmologist with dry eyes and then visits an orthopedic surgeon to improve back pain. In such a case, the visit time may be registered as the time when the first reception was received.

  A template 85 represents the type of template of the schema diagram. The template will be described later. The main complaint NO86 represents the main complaint included in the schema and is data associated with the main complaint NO131 included in the main complaint information database described later.

  Information related to a plurality of chief complaints can be registered for one schema. For example, the data of the two rows of the electronic medical chart NO81 “D1400012” shown in FIG. 5 is the same-day visit data, and the schema diagram NO84 is the same “SH00036”, but the main complaint NO86 is different. This indicates that two main complaint information are registered in the same schema.

  On the other hand, regarding the data of the two rows whose electronic medical chart No. 81 is “D1400015”, it is the visit data on the same day, but the schema diagram No. 84 is different. This indicates that different schema diagrams have been registered, and is data corresponding to a case where consultation is made in a plurality of medical departments.

  Further, regarding the data in which the electronic chart NO81 shown in FIG. 5 is “D1400014”, the schema diagram NO84 does not include the data. This is data when a medical worker or the like does not register main complaint information using a schema and directly inputs data into the electronic medical record. The system according to the present invention does not have the restriction that the schema diagram must be used.

  The illustrated database has a structure for explanation, and normalizing the table and rearranging the items are within the scope of assumptions.

  Next, a schema diagram template will be described. FIG. 6 is a diagram showing an example of a template selection screen of a schema diagram according to the embodiment of the present invention. In the present invention, when registering a main complaint in a patient examination, a template display window 88 of a schema is first displayed. In the template display window 88, prepared templates 89a to 89d are displayed.

  A medical worker or the like can use various templates depending on the patient's condition and the status of the main complaint to be registered. For example, when the patient's chief complaint is related to the whole body and a wide range of sites, a template including a front view and a rear view of the whole body, such as the template 89a or 89d, is selected. On the other hand, when the patient's chief complaint is related to the face portion or the head region, a template including a head view instead of the front view and rear view of the whole body is selected as in the template 89b or 89c. The templates are not limited to those shown in the figure, and templates such as only the head, only the hand, or only the upper body can be prepared. Moreover, it is also possible to use a schematic diagram or a photograph instead of the schema diagram.

  The template data is held in the HDD 13 of the server device, and is acquired by issuing an acquisition request from the medical institution terminal every time the medical institution terminal uses the template, or by installing or downloading to the medical institution terminal. May be stored in the HDD 33 and called from the HDD 33 each time it is used.

  FIG. 7 is a diagram showing an interface of the medical institution terminal when registering the main complaint according to the embodiment of the present invention. The schema shown in the figure is a case where the template 89a shown in FIG. 6 is selected. A medical worker or the like can input information to the schema using the input device 34 provided in the medical institution terminal 3.

  Next, registration of main complaint information will be described. FIG. 8 is a diagram showing an example of a flowchart of the main complaint information registration process according to the embodiment of the present invention.

  When a medical worker or the like selects a point by clicking the schematic diagram displayed on the display screen 35a of the medical institution terminal with, for example, a mouse cursor (step S1), the medical institution terminal 3 is selected by the part information receiving function 41. The coordinates of the selected point are extracted to identify the part (step S2).

  Here, in order to make it easy to select a part, the part name may be displayed in text by changing the color for each part, or by moving the mouse over the part to be selected. In addition, text may be directly input using the input device 34 of the medical institution terminal. The part specifying means is not limited to the determination using the coordinates, and may be a technique for determining the part clicked by overlapping the layers.

  Here, there are parts that are difficult to specify by clicking or the like, such as “whole body” and “nerve”. For such a part, if you click outside the specific range of the screen, etc., it will be treated as if you have specified "whole body", or you will have buttons for "whole body" and "nervous", and if the button is pressed, It may be considered as specified. An auxiliary design may be provided in which a list of selectable parts is displayed or a check box or the like is provided.

  Next, a process for extracting symptom candidates according to the present invention will be described. FIG. 9 is a diagram showing an example of a symptom / disease candidate database and an essential symptom database according to the embodiment of the present invention. FIG. 9A shows a symptom / disease candidate database 90 provided in the server apparatus 1. The symptom / disease candidate database 90 stores a site 91, a symptom 92, a disease candidate 93, and the like. The data included in the symptom / disease candidate database 90 indicates that there is a possibility of a disease candidate 93 when a symptom 92 appears in the site 91 of the patient's main complaint.

  FIG. 9B shows an essential symptom database 95 provided in the server apparatus 1. The essential symptom database 95 stores the disease 96, the site 97, the essential symptom 98, and the like in the essential symptom database 95. A disease 96 indicates that an essential symptom 98 occurs at the site 97. The process of extracting disease candidates will be described later.

  Here, data in the symptom / disease candidate database 90 will be described. For example, when the patient's chief complaint 91 is “whole body” and the symptom 92 is “fever”, the candidate diseases 93 are “mycoplasma pneumonia”, “infectious gastroenteritis”, “pertussis”, etc. . In the example of FIG. 9A, the information used to list candidates is the part 91 and the symptom 92, but information on the initial stage of the chief complaint, the elapsed period from the initial symptom, or the history of changes in the symptom is used. It is also possible to use a database structure that can be used to extract disease candidates.

  Next, the symptom candidate extraction process in the server device 1 will be described. The part information specified in step S2 is transmitted to the server apparatus 1 by the part information transmission function 42 of the medical institution terminal 3 (step S3). Thereafter, the server device 1 receives the symptom specifying information by the symptom specifying information receiving function 61 (step S4), and extracts the symptom candidate list by the symptom candidate extracting function 62 based on the part information (step S5).

  Here, the symptom candidate list extraction process in step S5 will be described in more detail. From the symptom / disease candidate database 90, the symptom 92 corresponding to the part 91 that matches the part information received in step S4 is extracted. Let the extracted symptom group be a symptom candidate list. For example, in FIG. 9A, if the received site information is “pharynx”, the extracted symptoms are “dry cough” and “throat soreness”, and these are used as a list of symptom candidates.

  Next, the server apparatus 1 transmits the symptom candidate list obtained in step S5 to the medical institution terminal 3 by the symptom candidate transmission function 63 (step S6). The medical institution terminal 3 receives the symptom candidate list from the server device 1 by the symptom candidate reception function 43 (step S7), and displays the symptom candidate list on the display screen 35a of the medical institution terminal (step S8).

  The medical staff or the like selects the symptom related to the patient's main complaint by clicking or the like from the displayed symptom candidate list (step S9). When the symptom is not found in the list, the symptom information may be input by inputting text using the input device 34 of the medical institution terminal 3, for example, a keyboard.

  The result of the above-described processing will be specifically described using a schema diagram. FIG. 10 is a diagram illustrating an example of a symptom selection result according to the chief complaint in the schema diagram according to the embodiment of the present invention. In step S1, a point mark 101 is attached to a place pointed by a medical worker or the like, and the main complaint window 100 is displayed.

  In the main complaint window 100, the pointed part name 107 is displayed. In the main complaint information input window 102, a symptom tab 103, a “from” tab 104, and a progress tab 105 are displayed, and the symptom tab 103 is displayed in a selected state. Further, in the main complaint information input window 102, the symptom candidate list displayed in the symptom candidate list display in step S8 is displayed.

  In the main complaint symptom selection in step S9, for example, when jaundice 106a, abnormal sweating 106b, and numbness 106c are selected, the main complaint symptom 108 is displayed in the main complaint window 100 simultaneously with the selection. Here, when selecting a plurality of main complaint symptoms, a plurality of symptoms may be selected by pressing and holding a control button, a shift button, or the like.

  Next, main complaint start information is selected (step S10). FIG. 11 is a diagram showing an example of a main complaint progress information selection or input screen in the schema according to the embodiment of the present invention. When the “from when” tab 104 of the main complaint information input window 102 shown in FIG. 10 is selected, the screen of FIG. 11A is displayed. The selection screen for main complaint start information includes a numerical value input window 111, a date designation button 112, and a start information unit 113.

  A medical worker or the like can input main complaint start information by directly inputting a numerical value into the numerical value input window 111 using the input device 34 of the medical institution terminal 3 and selecting one of the units 113. It is. Further, by clicking the date designation 112 or the like, the display can be switched to a calendar display screen as shown in FIG. The calendar display screen includes a button 114 for changing the month to be displayed and a date 115. By clicking the date 115 or the like, the date can be entered in the numerical value input window 111. FIG. 11C is an example of a screen display when a date is selected on the calendar display screen, and the selected date is displayed in the date window 116. In this case, “from” is automatically selected as the unit, and the option color may be changed as in units 118a to 118d to deactivate the option.

  Next, main complaint progress information is selected (step S11). FIG. 11D shows a main complaint progress information selection screen, which is displayed by clicking the progress tab 105 of the main complaint information input window 102 shown in FIG. Four types of options related to the progress information are displayed on the main complaint progress information selection screen. In FIG. 11D, “suddenly worse” 120 is selected. You may make it change the choice of progress information for every symptom.

  After selecting the main complaint progress information, it is temporarily stored as main complaint information in the RAM 32 of the medical institution terminal 3 (step S12). Here, the selected main complaint information is displayed in the main complaint window 100.

  If the input of the main complaint is completed, the main complaint information can be registered in the server device 1 by pressing the OK button 109. The main complaint information registration process will be described later. On the other hand, when the cancel button 110 is pressed, information that has not been registered in the server device among the main complaint information input so far is lost. Here, a confirmation message indicating that unregistered data is lost may be displayed.

  Next, the case where selection of the main complaint information is completed and the OK button is pressed in step S13 of FIG. 8 will be described (YES in step S13). The medical institution terminal 3 transmits all input main complaint information to the server device 1 by the main complaint information transmission function 49 (step S14). The server device 1 receives the main complaint information by the main complaint information receiving function 65 (step S15), and registers the received main complaint information in the main complaint information database 120 stored in the HDD 13 (step S16).

  FIG. 12 is a diagram showing an example of the main complaint information database according to the embodiment of the present invention. The main complaint information database 120 stores the part 122, the coordinate X123, the coordinate Y124, the update date 125, the symptom 126, the initial stage 127, the progress 128, and the like in association with the main complaint NO121. The part 122 represents the part name specified by the part specification in step S2, and the coordinates X123 and the coordinate Y124 represent the specified coordinates. The update date and time 125 represents the system date and time in the server device 1 when the main complaint information is registered or updated, and the symptom 126 represents the main complaint symptom selected in the main complaint symptom selection in step S9. The initial period 127 and the progress 128 represent values selected in the main complaint initial period information selection in step S10 and the main complaint progress information selection in step S11, respectively.

  After registering the main complaint information, disease candidates are extracted from all main complaint information (step S17). Here, a plurality of extracted disease candidates may correspond.

  Next, disease candidate list extraction processing will be described. FIG. 13 is a diagram illustrating an example of a disease candidate list extraction process according to the embodiment of the present invention. First, a list of disease candidates 93 is acquired from the symptom / disease candidate database 90 (step S30). Next, the presence or absence of main complaint information is determined (step S31). If there is no main complaint information (NO in step S31), all disease candidates 93 registered in the symptom / disease candidate database 90 are displayed in the disease candidate list. Alternatively, when there is no main complaint information, nothing may be extracted and a transition to another screen may be made.

  If there is main complaint information (YES in step S31), if there is a plurality of main complaint information, one main complaint information is selected to be processed from the top data included in the array (step S32), and selected. Based on the main complaint information and the disease candidate list acquired in step S30, the corresponding disease candidates are extracted from the symptom / disease candidate database 90 (step S33). The extracted list of disease candidates is updated by replacement with the disease candidate list acquired in step S30 (step S34).

  It is determined whether disease candidate extraction processing has been performed for all main complaint information (step S35). If uncompleted main complaint information exists (NO in step S35), uncompleted main complaint information is selected again (step S35). S32), disease candidates are also extracted for the main complaint information (step S33). However, the disease candidate extraction process performed here is performed using the disease candidate list already updated in step S34.

  Repeat the above process for all chief complaints. That is, when there are a plurality of main complaints, only disease candidates common to all the main complaints are finally extracted.

  The extracted disease candidate list is transmitted to the medical institution terminal 3 by the disease candidate transmission function 67 of the server device 1 (step S18). The medical institution terminal 3 receives the disease candidate list from the server device 1 by the disease candidate reception function 50 (step S19), and displays the received disease candidate list on the display screen 35a (step S20). A medical worker or the like selects the disease related to the patient's main complaint by clicking or the like from the displayed disease candidate list, and the medical institution terminal 3 receives the selection of the disease information by the disease reception function 52.

  After the common disease candidates are extracted, although not shown in the figure, in order to further increase the possibility that the disease listed as a disease candidate is a symptom related to the patient's main complaint, the disease and main complaint included in the extracted disease candidate list Perform processing to ensure consistency with information.

  For example, it is assumed that “Mycoplasma pneumonia” and “Pertussis” are included in the common disease candidate list, and the chief complaint information is only the symptoms of “dry cough” in “pharynx”. Here, the essential symptom database 95 is referred to, and the symptom that always exists regarding the disease is confirmed.

  First, when confirming “mycoplasma pneumonia”, an essential symptom is “fever” in “whole body”. However, as described above, the main complaint information does not include information on “whole body” and “fever”. Therefore, “Mycoplasma pneumonia” is excluded from disease candidates.

  Next, confirming “pertussis”, the essential symptom is “dry cough” in “pharynx”. That is, “pertussis” remains in the disease candidate because it matches the main complaint information.

  In other words, disease candidates common to a plurality of input symptoms are extracted, the essential symptom database is referred to for the extracted disease candidates, and if the essential symptoms are input as symptoms, they are left in the disease candidates, and the essential symptoms If no is input as a symptom, it is possible to narrow down disease candidates by excluding them from the disease candidates. As described above, the information on the disease 96, the site 97 and the essential symptom 98 included in the data of the essential symptom database 95 is consistent with the information on the disease and the main complaint information included in the disease candidate, and more possible. A list of highly likely disease candidates can be provided to healthcare professionals.

  Although the extracted disease candidate list is not shown, it is displayed on the display screen 35a of the medical institution terminal 3, and a medical worker or the like can transcribe as a name of the received disease on the electronic medical record by selecting the disease candidate. If a receipt disease name considered by a health care worker or the like does not exist in a disease candidate, it may be possible to respond by directly inputting characters.

  As described above, the medical record creation support system according to the present invention is capable of presenting a medical worker or the like with a disease that can be a disease candidate based on information related to a patient's main complaint. As a result, the burden on medical personnel and the like is reduced, and it is effective in preventing medical errors such as oversight of diseases, and also has a role of medical assistance.

  By the way, the system according to the present invention is provided with a function of registering a plurality of main complaint information and a memo input function to a schema by a medical worker or the like. FIG. 14 is a diagram showing an example of a screen on which a plurality of chief complaints are registered according to the embodiment of the present invention.

  First, a function for registering a plurality of main complaint information will be described. When it is desired to add a plurality of main complaint information, the main complaint addition button 132 is pressed, and the main complaint information registration process shown in FIG. 8 is performed. When two main complaint information is registered as shown in FIG. 14, the first registered main complaint information window 131a and the next registered main complaint information window 131b are displayed. As described above, even if a plurality of main complaint information is registered in one drawing, the main complaint information windows are displayed without overlapping, and a medical worker or the like can grasp patient information at a glance.

  Next, a memo input function for drawings will be described. For example, when the toolbox icon 134 is clicked, a pencil tool 135a, an eraser tool 135b, and a clear all button 136 are displayed. When the pencil tool 135a is clicked and dragged to the schematic diagram with a mouse pointer or the like, a memo 133 can be written. The range in which memos can be written may be limited.

  When the eraser tool 135b is clicked, the written content can be erased by dragging the written content with the pencil tool 135a. When the clear all button 136 is clicked or the like, all the contents described by the pencil tool 135a in the drawing are erased.

  By the way, the schema after being registered in the server device by pressing the OK button can be displayed again from the electronic medical record. Here, it is also possible to update information in the schema after redisplay. However, the updated information is retained so that the history can be traced, and it is necessary to function as a medical record even if a medical worker or the like does not consciously manage in preparation for a lawsuit or the like.

  In addition, a function may be provided in which a schematic diagram of a patient is arranged in time series so that the old schematic diagram is at the bottom and the latest schematic diagram is at the top without switching the screen. By doing in this way, a medical worker etc. becomes easy to grasp the state in a patient's time series. Further, a schema diagram at a certain point in the past and a schema diagram at the latest point in time may be displayed side by side on the screen. It is possible to facilitate the comparison of symptoms and improve the convenience of medical staff and the like.

  By the way, although this invention was described as a system, it is also possible to provide the function of the server apparatus 1 to a single medical institution apparatus. FIG. 15 is a diagram illustrating an example of a main complaint information registration process in the medical institution apparatus according to the embodiment of the present invention. As shown in FIG. 15, it is possible to cause the medical institution apparatus to execute the main complaint information registration process in FIG. 8. In this case, all the storage devices and the like provided in the server device 1 are provided in the medical institution device, and the disease candidate list extraction process illustrated in FIG. 13 is executed by the medical institution device.

  Furthermore, in the medical record creation system of the present invention, the symptoms that are extracted when selecting a part of the schema diagram are extracted by displaying the applicable main complaint information in the schema diagram and displayed. Is also possible.

  FIG. 16: is a figure which shows an example of the flowchart of the main complaint information registration process in the case of extracting the symptom candidate list concerning embodiment of this invention in consideration of the existing main complaint information. The process of point selection (step S60) and part specification (step S61) is the same as the process shown in FIG. Here, the point which extracts the existing main complaint information differs (step S62). The existing main complaint information refers to main complaint information other than the main complaint information to be registered in the same schema diagram, regardless of whether the information is registered in the server device. That is, when registering certain main complaint information and other main complaint information, the other main complaint information is extracted when registering the main complaint information after registering the other main complaint information.

  The part information specified in step S61 and the existing main complaint information extracted in step S62 are combined into symptom specifying information and transmitted to the server device 1 (step S63). The server device 1 receives the symptom specifying information (step S64), and extracts a symptom candidate list based on the symptom specifying information (step S65). The processing from step S66 to step S80 corresponds to step S6 to step S20 in FIG.

  Here, the symptom candidate list extraction process will be described. FIG. 17 is a diagram illustrating an example of a flowchart of a symptom candidate list process in a case where a symptom candidate list according to an embodiment of the present invention is extracted in consideration of existing main complaint information. The presence / absence of existing main complaint information is determined (step S81), and if there is no existing main complaint information (NO in step S81), the symptom related to the site specified in step S2 is extracted from the symptom / disease candidate database 90 (step S87). .

  If there is existing chief complaint information (YES in step S81), all disease candidates 93 registered in the symptom / disease candidate database 90 are first extracted as a disease candidate list (step S82). If there is a plurality of existing main complaint information, one existing main complaint information is selected for processing from the top data included in the array (step S83), and the selected existing main complaint information and the disease candidate acquired in step S82 Based on the list, a corresponding disease candidate is extracted from the symptom / disease candidate database 90 (step S84). The extracted disease candidate list is updated by replacing the disease candidate list acquired in step S82 (step S85).

  It is determined whether disease candidates have been extracted for all existing main complaint information (step S86). If there is incomplete existing main complaint information (NO in step S86), the incomplete existing main complaint information is selected again. (Step S83), disease candidates are extracted from the existing main complaint information (Step S84). However, the disease candidate extraction process is performed using the disease candidate list already updated in step S85.

  The above process is repeated for all existing chief complaint information. That is, when there are a plurality of main complaints, only the common diseases are finally extracted from the diseases that can be related to all the main complaint information.

  When disease candidate extraction processing has been performed for all existing main complaint information (YES in step S86), symptoms 92 associated with each disease candidate 93 are extracted from the extracted disease candidate list using a symptom / disease candidate database 90. (Step S87) to obtain a symptom candidate list.

  Here, in the symptom candidate list extraction process, when there is no disease candidate common to the main complaint information in the symptom candidate list, an error message indicating that the symptom related to the registered main complaint information is not found may be displayed.

  As described above, by creating a symptom candidate list in consideration of the main complaint information already input, the number of choices of the main complaint symptom selected in step S69 can be reduced, so that medical treatment can be performed efficiently. can do.

DESCRIPTION OF SYMBOLS 1 Server apparatus 100 Main complaint window 11 Control part 12 RAM
120 Main complaint information database 13 HDD
14 Communication Interface 2 Communication Network 3 Medical Institution Terminal 31 Control Unit 32 RAM
33 HDD
34 Input Device 35 Display Device 36 Communication Interface 70 Patient Information Database 80 Electronic Medical Record Database 88 Template Display Window 90 Symptom / Disease Candidate Database 95 Essential Symptom Database

Claims (5)

A medical record creation support system comprising a medical institution terminal in which a user can input a medical record, and a server device capable of communication connection with the medical institution terminal,
Medical institution terminal
Part information receiving means for receiving part information related to a part constituting the living body in response to a user's input operation;
Site information transmitting means for transmitting the received site information to the server device;
Symptom candidate receiving means for receiving a symptom candidate transmitted from a server device;
A symptom selection receiving means for receiving a symptom selection from the received symptom candidates in response to a user input operation;
Server device
A symptom candidate storage means for storing a part constituting a living body and a symptom that may develop at the part in association with each other;
Site information receiving means for receiving site information transmitted from a medical institution terminal;
Symptom candidate extraction means for extracting a symptom corresponding to a part included in the received part information as a symptom candidate from the symptom stored in the symptom candidate storage means;
Symptom candidate transmission means for transmitting the extracted symptom candidate to a medical institution terminal,
The medical institution terminal or the server device includes a main complaint information storage unit that stores other main complaint information about a part different from the part,
The server device further
Disease candidate storage means for storing a symptom and a disease candidate that can be identified from the symptom in association with each site;
A disease candidate extraction means for extracting, as a disease candidate, a disease corresponding to a symptom included in other main complaint information stored in the main complaint information storage means from the disease stored in the disease candidate storage means;
The symptom candidate extraction unit extracts a symptom corresponding to the part included in the part information received by the part information receiving unit and corresponding to the disease candidate extracted by the disease candidate extraction unit in the disease candidate storage unit. , Medical record creation support system. A server device that can be connected to a medical institution terminal through which a user can input medical records by communication,
A symptom candidate storage means for storing a part constituting a living body and a symptom that may develop at the part in association with each other;
A part information receiving means for receiving part information relating to a part constituting the living body, transmitted from a medical institution terminal;
Symptom candidate extraction means for extracting a symptom corresponding to a part included in the received part information as a symptom candidate from the symptom stored in the symptom candidate storage means;
A symptom candidate transmission means for transmitting the extracted symptom candidate to a medical institution terminal;
Main complaint information storage means for storing other main complaint information about a portion different from the portion;
Disease candidate storage means for storing a symptom and a disease candidate that can be identified from the symptom in association with each site;
A disease candidate extraction means for extracting, as a disease candidate, a disease corresponding to a symptom included in other main complaint information stored in the main complaint information storage means from the disease stored in the disease candidate storage means;
The symptom candidate extraction unit extracts a symptom corresponding to the part included in the part information received by the part information receiving unit and corresponding to the disease candidate extracted by the disease candidate extraction unit in the disease candidate storage unit. , Server device. A medical institution terminal in which a user can input a medical record, and a medical record creation support method executed in a server device that can be connected to the medical institution terminal by communication,
In the medical institution terminal,
In response to an input operation to a user's input unit, receiving part information regarding a part constituting the living body;
Transmitting the received part information to the server device via the communication interface unit;
Receiving the symptom candidate transmitted from the server device via the communication interface unit;
Receiving a selection of symptoms from the received symptom candidates in response to an input operation to the input unit of the user,
In the server device,
Receiving the site information transmitted from the medical institution terminal via the communication interface unit;
In the control unit, the symptom corresponding to the part included in the received part information is extracted as a symptom candidate from the symptom stored in association with the part constituting the living body in the storage device and the symptom that can develop in the part And steps to
Transmitting the extracted symptom candidates to the medical institution terminal via the communication interface unit;
Included in the other main complaint information about the part different from the part stored in the storage part from the disease stored in the storage part that stores the symptom and the disease candidate that can be identified from the symptom in association with each part. Extracting a disease corresponding to the symptom as a disease candidate,
The step of extracting the symptom candidate is a symptom corresponding to the part included in the part information received in the step of receiving the part information, and the symptom corresponding to the disease candidate extracted in the step of extracting the disease candidate is extracted. , Medical record creation support method. A medical institution device that allows a user to input medical records,
A symptom candidate storage means for storing a part constituting a living body and a symptom that may develop at the part in association with each other;
Part information receiving means for receiving part information related to a part constituting the living body in response to a user's input operation;
Symptom candidate extraction means for extracting, as a symptom candidate, a symptom corresponding to a part included in the received part information from the symptom stored in the symptom candidate storage means;
A symptom selection accepting means for accepting a symptom selection from the symptom candidates extracted by the symptom candidate extracting means according to a user's input operation;
Main complaint information storage means for storing other main complaint information about a portion different from the portion;
Disease candidate storage means for storing a symptom and a disease candidate that can be identified from the symptom in association with each site;
A disease candidate extraction means for extracting, as a disease candidate, a disease corresponding to a symptom included in other main complaint information stored in the main complaint information storage means from the disease stored in the disease candidate storage means;
The symptom candidate extraction unit extracts a symptom corresponding to the part included in the part information received by the part information receiving unit and corresponding to the disease candidate extracted by the disease candidate extraction unit in the disease candidate storage unit. , Medical institution equipment. A medical record creation support program executed by a medical institution device that allows a user to input a medical record,
Medical institution equipment,
A symptom candidate storage means for storing a part constituting a living body and a symptom that may develop at the part in association with each other;
Part information receiving means for receiving part information related to a part constituting the living body in response to a user's input operation;
Symptom candidate extraction means for extracting, as a symptom candidate, a symptom corresponding to a part included in the received part information from the symptom stored in the symptom candidate storage means;
A symptom selection accepting means for accepting a symptom selection from the symptom candidates extracted by the symptom candidate extracting means according to a user's input operation;
Main complaint information storage means for storing other main complaint information about a portion different from the portion;
Disease candidate storage means for storing a symptom and a disease candidate that can be identified from the symptom in association with each site;
From the disease stored in the disease candidate storage means, function as a disease candidate extraction means for extracting as a disease candidate a disease corresponding to the symptom included in other main complaint information stored in the main complaint information storage means,
The symptom candidate extraction unit extracts a symptom corresponding to the part included in the part information received by the part information receiving unit and corresponding to the disease candidate extracted by the disease candidate extraction unit in the disease candidate storage unit. , Medical record creation support program.

Images