JP2019185255A - Electronic medical record editing program, electronic medical record editing method, and information processing apparatus - Google Patents

Abstract

To properly manage electronic medical chart data edited in conjunction with other computers.SOLUTION: A display control part 34 displays an editing screen of a piece of electronic medical chart data, when a piece of information is input from a mobile terminal 60 associated in advance while the editing screen is displayed, an electronic medical chart data update unit 36 inputs information entered at a specified position or a predetermined position of the electronic medical chart data. When an instruction to save the edited electronic medical chart data is input, the store processing unit 38 assigns a new version number to the edited electronic medical chart data and associates the electronic medical chart data with the new version number, and save it on the server 10.SELECTED DRAWING: Figure 3

Description

  The present invention relates to an electronic medical record editing program, an electronic medical record editing method, and an information processing apparatus.

  In medical institutions such as hospitals and clinics, when a doctor or the like creates, edits, or browses electronic medical record data, a PC (Personal Computer) installed in an examination room is often used. In recent years, in order to improve convenience in medical examinations, electronic medical record data is sometimes edited and viewed using a portable terminal such as a smartphone (see, for example, Patent Document 1).

  For example, when pasting an image photographed with a smartphone to electronic medical record data, the electronic medical record data is read, the photographed image is pasted on the read electronic medical record data, and the electronic medical record data is saved after pasting.

JP 2014-198244 A

  However, if the electronic medical record data is edited and stored on a PC or a smartphone, the version number of the electronic medical record data is counted up every time the data is stored. Due to the nature of electronic medical record data, frequent updates of electronic medical record data are considered to mean that some sort of problem has occurred, so electronic medical record data with a large version is subject to auditing in hospitals. May be.

  When editing work is being performed independently from multiple devices, it is necessary to count up the version number. On the other hand, when a certain device is used as means for acquiring information to be input to the electronic medical record data ( In the case where a certain device is not used for substantial editing work, a mechanism for preventing the version number from increasing is necessary.

  In one aspect, the present invention relates to electronic medical record data when electronic medical record data is edited in cooperation with another apparatus that is a means for acquiring information input to the electronic medical record data. It is an object of the present invention to provide an electronic medical record editing program, an electronic medical record editing method, and an information processing apparatus capable of managing the version number of the information.

  In one aspect, the electronic medical record editing program displays an electronic medical record data editing screen on a display unit of a computer, and is associated with the computer in advance in a state where the editing screen is displayed on the display unit. When information is input from another computer, the information is input to a designated position or a predetermined position of the electronic medical record data, and an instruction to save the electronic medical record data to which the information is input in the computer Is input to the electronic medical record data to which the information is input, and the electronic medical record data is stored in a storage unit that stores the electronic medical record data in association with the version number. It is a program for making it run.

  When the electronic medical record data is edited in cooperation with another computer, the version number of the electronic medical record data can be managed.

It is a figure showing roughly the composition of the electronic medical chart system concerning one embodiment. FIG. 2A is a diagram illustrating a hardware configuration of the doctor terminal, and FIG. 2B is a diagram illustrating a hardware configuration of the portable terminal. It is a functional block diagram of a doctor terminal and a portable terminal. It is a flowchart which shows the whole process of a doctor terminal. FIG. 5A is a diagram illustrating an example of an electronic medical record data editing screen, and FIG. 5B is a diagram illustrating data developed on the memory of the doctor terminal. FIG. 6A is a diagram showing a state where the menu screen is displayed on the display unit of the mobile terminal, and FIG. 6B is a diagram showing a state where the function selection screen is displayed on the display unit of the mobile terminal. It is. It is a flowchart which shows the process of a portable terminal when an "ID reading" button is clicked. It is a figure which shows the state of the display part of a portable terminal at the time of starting a code reader. It is a figure for demonstrating a message | telegram. It is a figure which shows ID authentication data. FIG. 11A is a flowchart showing processing of the mobile terminal when the “camera activation” button is clicked, and FIG. 11B is processing of the mobile terminal when the “schema input” button is clicked. It is a flowchart which shows. FIG. 12A to FIG. 12D are diagrams (part 1) for explaining the processing of FIG. 11A. FIG. 13A to FIG. 13C are diagrams (part 2) for explaining the processing of FIG. FIGS. 14A and 14B are diagrams showing original image data and hand-drawn image data generated when the process of FIG. 11A is executed. It is a figure which shows the state in which the schema selection screen was displayed on the display part of the portable terminal. FIGS. 16A and 16B are diagrams showing original image data and hand-drawn image data generated when the process of FIG. 11B is executed. It is a flowchart which shows the process of a portable terminal when the "voice input" button is clicked. It is a figure which shows the state by which the audio | voice input screen was displayed on the display part of the portable terminal. It is a figure which shows audio | voice input data. FIG. 20A is a flowchart showing the processing of the mobile terminal when the “prescription palette” button is clicked, and FIG. 20B is the processing of the mobile terminal when the “disease name palette” button is clicked. It is a flowchart which shows. FIG. 21A is a diagram showing a state where a prescription selection screen is displayed on the display unit of the mobile terminal, and FIG. 21B is a diagram showing prescription data. FIG. 22A is a diagram illustrating a state where a disease name selection screen is displayed on the display unit of the mobile terminal, and FIG. 22B is a diagram illustrating disease name data. It is a flowchart which shows the process of a doctor terminal at the time of using a portable terminal as an input device.

  Hereinafter, an embodiment of an electronic medical record system will be described in detail with reference to FIGS. FIG. 1 schematically shows a configuration of an electronic medical chart system 100 according to an embodiment. The electronic medical chart system 100 of this embodiment is a system used in medical institutions such as hospitals and clinics, and is used for creation, editing, management, and the like of electronic medical chart data.

  As shown in FIG. 1, the electronic medical chart system 100 includes a server 10, a plurality of information processing apparatuses and a doctor terminal 70 as a computer, and a portable terminal 60 as another computer. The server 10, the doctor terminal 70, and the portable terminal 60 are connected to a network 80 such as the Internet.

  The server 10 is a data server having a storage unit that manages electronic medical record data.

  The doctor terminal 70 is a terminal used by a user such as a doctor in an examination room or the like. For example, the doctor terminal 70 is a desktop or notebook PC (Personal Computer) used for creating or editing electronic medical record data when a doctor examines a patient. It shall be. At the doctor terminal 70, the electronic medical record data is read from the server 10 and displayed. In addition, when an instruction to save electronic medical record data created and edited in the doctor terminal 70 is input, the electronic medical record data is transmitted to the server 10 and the electronic medical record data is stored in the server 10. Note that the version number of the newly created electronic medical record data is set to “1”. On the other hand, when the existing electronic medical record data is edited, the version number is set to a version number obtained by counting up (+1) the version number of the existing electronic medical record data by one. In this case, the edited electronic medical record data is managed by the server 10 as data different from the electronic medical record data before editing.

  FIG. 2A schematically shows the hardware configuration of the doctor terminal 70. As shown in FIG. 2A, a doctor terminal 70 includes a CPU (Central Processing Unit) 190, a ROM (Read Only Memory) 192, a RAM (Random Access Memory) 194, and a storage unit (here, an HDD (Hard Disk Drive)). 196, a network interface 197, a display unit 193, an input unit 195, a portable storage medium drive 199, and the like. The display unit 193 includes a liquid crystal display and the like, and the input unit 195 includes a keyboard, a mouse, a touch panel, and the like. Each component of the doctor terminal 70 is connected to the bus 198. In the doctor terminal 70, a program (including an electronic medical record editing program) stored in the ROM 192 or the HDD 196 or a program (including an electronic medical record editing program) read from the portable storage medium 191 by the portable storage medium drive 199. When executed by the CPU 190, the functions of the respective units shown in FIG. 3 are realized. 3 may be realized by an integrated circuit such as an application specific integrated circuit (ASIC) or a field programmable gate array (FPGA). Details of each part in FIG. 3 will be described later.

  The portable terminal 60 is a smartphone or a tablet terminal used by a user such as a doctor. The portable terminal 60 has a function (application) for creating and editing electronic medical record data, and a function (application) used as an input device when creating and editing electronic medical record data in the doctor terminal 70. In the present embodiment, when the electronic medical record data is created / edited using the mobile terminal 60, the electronic medical record data created / edited in the mobile terminal 60 can be stored in the server 10. When 60 is used as an input device, electronic medical record data cannot be stored in the server 10 from the portable terminal 60.

  FIG. 2B schematically shows the hardware configuration of the mobile terminal 60. As shown in FIG. 2B, the portable terminal 60 includes a CPU 290, a ROM 292, a RAM 294, a storage unit (HDD) 296, a network interface 297, a display unit 293, a touch panel 295, a microphone 287, a camera 289, and a portable storage medium. Drive 299 and the like. Display unit 293 includes a liquid crystal display or the like. The touch panel 295 is provided on the surface of the display unit 293, receives information corresponding to the movement of the user's finger or the movement of the touch pen as an input, and transmits the information to the CPU 290. The microphone 287 receives the user's voice data as an input and transmits it to the CPU 290. The camera 289 transmits an image taken in response to a user operation to the CPU 290. Each component of the portable terminal 60 is connected to a bus 298. In the portable terminal 60, the function of each unit shown in FIG. 3 is realized by the CPU 290 executing the program stored in the ROM 292 or the HDD 296 or the program read from the portable storage medium 291 by the portable storage medium drive 299. Is done. Note that the function of each unit of the mobile terminal 60 of FIG. 3 may be realized by an integrated circuit such as an ASIC or FPGA, for example.

  Here, the functions of the portable terminal 60 and the doctor terminal 70 will be described in detail with reference to FIG.

(About functions of the mobile terminal 60)
As shown in FIG. 3, in the mobile terminal 60, functions as the display control unit 20, the input reception unit 22, the processing unit 24, and the message transmission unit 28 are realized by the CPU 290 executing a program.

  The display control unit 20 displays various screens on the display unit 293 in accordance with user operations.

  The input receiving unit 22 transmits information input from the touch panel 295, the microphone 287, the camera 289, and the like to the processing unit 24.

  The processing unit 24 executes various processes based on the information received from the input receiving unit 22.

  For example, when an application for creating / editing electronic medical record data is activated in the mobile terminal 60, the processing unit 24 executes processing related to creation and editing of electronic medical record data based on information received by the input receiving unit 22. To do. Specifically, the processing unit 24 reads the patient's electronic medical record data designated by the user from the server 10 and causes the display control unit 20 to display an editing screen. When the user inputs a character or the like, the processing unit 24 receives the input information from the input receiving unit 22 and inputs a character on the editing screen. When the user inputs a storage instruction for electronic medical record data, the storage instruction is received from the input receiving unit 22, and the electronic medical record data is transmitted to the server 10 and stored.

  For example, in the portable terminal 60, when an application that uses the portable terminal 60 as an input device (as an acquisition unit for information input to the electronic medical record data) is activated, the processing unit 24 captures images with the camera 289. Information on the selected image, audio information input to the microphone 287, information selected by the user using the touch panel 295, and the like are received from the input receiving unit 22. Then, the processing unit 24 generates data (telegram) to be transmitted to the doctor terminal 70 using the received information, and delivers the generated telegram to the telegram transmission unit 28.

  The message transmission unit 28 transmits the message generated by the processing unit 24 to the doctor terminal 70. In addition, the message | telegram transmission part 28 shall transmit the message | telegram produced | generated by the process part 24 only with respect to the doctor terminal 70 previously paired. The message transmission unit 28 may transmit a message to the doctor terminal 70 using a communication method such as Bluetooth (registered trademark), or may transmit a message via a network such as the Internet or WiFi. Good.

(About functions of the doctor terminal 70)
As shown in FIG. 3, in the doctor terminal 70, the CPU 190 executes a program, whereby the input reception unit 30, the electronic medical record data acquisition unit 32, the display control unit 34, the electronic medical record data update unit 36 as an update unit, The function as the storage processing unit 38 is realized.

  The input receiving unit 30 receives information input by the user via the input unit 195 and receives a message transmitted from the portable terminal 60 (the message transmitting unit 28).

  The electronic medical record data acquisition unit 32 reads out the electronic medical record data of the patient designated by the user from the server 10 and passes it to the display control unit 34.

  The display control unit 34 displays on the display unit 193 an electronic medical record data editing screen read out from the server 10 by the electronic medical record data acquiring unit 32 or an editing screen for creating new electronic medical record data.

  The electronic medical record data update unit 36 inputs (reflects) information input by the user via the input unit 195 to the electronic medical record data editing screen or edits the electronic medical record data based on the electronic message received from the mobile terminal 60 Update the screen.

  When the user inputs an instruction to save electronic medical record data via the input unit 195, the storage processing unit 38 transmits the electronic medical record data to the server 10 and stores it.

(Processing of electronic medical record system 100)
Next, processing executed in the electronic medical record system 100 will be described in detail. In the following, when creating or editing electronic medical record data in the doctor terminal 70, the portable terminal 60 is used as an input device (that is, the portable terminal 60 is not used for substantial editing of electronic medical record data). Case) will be described.

  As a premise that this process is executed, the doctor terminal 70 executes the process of FIG. Specifically, in the doctor terminal 70, in step S300 of FIG. 4, the input reception unit 30 waits until a request for creation or editing of electronic medical record data is received from the user. When the user makes a request to create or edit electronic medical record data, the input receiving unit 30 notifies the electronic medical record data acquiring unit 32 or the display control unit 34 to that effect. Thereafter, the process proceeds to step S302. Note that “creating” electronic medical record data means creating new electronic medical record data, and “editing” electronic medical record data means changing a part of existing electronic medical record data.

  In step S302, the display control unit 34 displays a new creation screen or an electronic medical record data editing screen. Here, when the user inputs a request to create electronic medical record data, the display control unit 34 generates an edit screen for newly creating electronic medical record data and displays it on the display unit 193. On the other hand, when the user designates a patient and inputs an electronic medical record data editing request, the electronic medical record data acquisition unit 32 reads the electronic medical record data of the designated patient from the server 10 and receives it by the display control unit 34. hand over. Then, the display control unit 34 generates an edit screen using the received electronic medical record data, and displays it on the display unit 193. In the following description, for convenience of explanation, it is assumed that an electronic medical record data editing request has been issued by the user.

  FIG. 5A shows an example of an electronic medical record data editing screen. The edit screen includes an S (subjective) column, an O (objective) column, an A (assessment) column, a P (plan) column, a prescription column, a disease name column, and the like. When information such as characters and images is already input in each column, the characters and images are displayed in each column of the editing screen. When the electronic medical record data editing screen is displayed, data as shown in FIG. 5B is developed on the memory of the doctor terminal 70. When each column of the edit screen is edited, the edited content is reflected in the data on the memory in FIG. The data on the memory in FIG. 5B includes an original layer and a hand-drawn layer in addition to an area for storing information input in the S column, O column, A column, P column, prescription column, and disease name column. There is also an area to store. Details of the area for storing the original layer and the hand-drawn layer will be described later.

  After the process of step S302 is performed, the user can perform editing work on the electronic medical record data. In this editing work, the portable terminal 60 can be used as an input device. Hereinafter, processing when the portable terminal 60 is used as an input device in the editing work of the electronic medical record data will be described.

(About processing of portable terminal 60)
When the user uses the portable terminal 60 as an input device, the “electronic medical record input” application is selected with the menu screen displayed on the display unit 293 of the portable terminal 60 as shown in FIG. In this case, the display control unit 20 displays a function selection screen on the display unit 293 as shown in FIG. On the function selection screen, one of “camera activation”, “schema input”, “speech input”, “ID reading”, “prescription palette”, and “disease name palette” can be selected (clicked). Hereinafter, the process of the portable terminal 60 when each button is clicked will be described in detail. In the present embodiment, the processing of FIG. 7, FIG. 11 (a), FIG. 11 (b), FIG. 17, FIG. 20 (a), and FIG. It shall be.

<When the “Read ID” button is clicked>
When editing electronic medical record data, there are cases where the user wants to input information such as a patient or a doctor by reading a two-dimensional code or bar code using the portable terminal 60 in order to reduce the input burden. In this case, the user clicks an “ID read” button in the function selection screen. It is assumed that the doctor's two-dimensional code or barcode is printed on, for example, a doctor's name tag, and the patient's two-dimensional code or barcode is printed on a bracelet or the like worn by the patient.

  In step S10 of FIG. 7, since the input reception unit 22 is on standby until the “ID read” button is clicked from the function selection screen, when the user clicks the “ID read” button, the process proceeds to step S12 of FIG. Transition.

  In step S12, the processing unit 24 activates the code reader. As described above, when the code reader is activated, the processing unit 24 displays a screen as illustrated in FIG. 8 on the display unit 293 via the display control unit 20.

  Next, in step S14, the processing unit 24 performs code reading in accordance with a user operation. In this case, the processing unit 24 performs imaging using the camera 289 in accordance with the user's operation, and obtains information such as a patient and a doctor by analyzing a two-dimensional code or barcode included in the captured image. The processing unit 24 stores information read from the two-dimensional code or bar code in a message to be transmitted to the doctor terminal 70.

  Next, in step S16, the processing unit 24 forms a message before transmission. The processing unit 24 delivers the formed electronic message to the electronic message transmission unit 28. Next, in step S <b> 18, the message transmission unit 28 transmits a message to the doctor terminal 70. Thereafter, the process returns to step S10.

  Here, it is assumed that the message is data having contents as shown in FIG. Specifically, the message contains item no. = 1-12, and each item includes “processing date”, “processing time”, “terminal ID”, “processing category”, “tool category”, “sequence ID”, “message” “Length”, “Output target category”, “Format type”, “body1”, “body2”, “Terminal”. The attribute of the data of the items “processing date” and “processing time” is “numerical type”, and is data indicating the processing date and time. The attribute of the data of the item “terminal ID” is “character type”, and is data indicating identification information of the portable terminal 60. The attribute of the data of the item “processing category” is “character type”, “01” means “new” data, “02” means “update” data, “03” If so, it means “deleted” data. In the present embodiment, an example in which new information is input from the mobile terminal 60 will be described. Therefore, the item “processing category” is basically “01”.

  The data attribute of the item “tool classification” is “numeric type”, “1” is ID authentication, “2” is image pasting, “3” is schema input, “4” is voice input, “5” is prescription Palette, “6” means disease name palette. The attribute of the data of the item “sequence ID” is “numeric type”, which is data of sequence identification information. The attribute of the data of the item “message length” is “numerical type”, which is data indicating the length of the message.

  The attribute of the data of the item “output target category” is “numerical type”, and is data indicating where information is input in the electronic medical record data. If the output target category is “0”, it means that information is input to “caret position (cursor position)”, and if it is “1”, it means that information is input to “S column”. Further, “2” means that information is input in “O column”, “3” means that “A column” is entered, and “4” means that information is inputted in “P column”. Further, “5” means that information is input to the “prescription column”, and “6” means that information is input to the “disease name column”.

  The data attribute of the item “format type” is “numeric type”, “0” if the data format is a character string, “1” if the data format is an image (original layer), and an image (hand-drawn layer). ) Is “2”. Details of the original layer and the hand-drawn layer will be described later.

  The attribute of the data of item “body1” is “numeric type”, the attribute of the data of item “body2” is “character type”, “body1” stores the binary data of the image, and “body2” Stores character string data. The attribute of the data of the item “end” is “character type”, and “Z” indicating the end of the message is stored.

  When the process of FIG. 7 is executed, a message as shown in FIG. 10 is generated. In the message of FIG. 10, the item “tool classification” is “1” meaning ID authentication, the item “output target classification” is “0” meaning the caret position, and the item “format type” is a character string. It is “0”. The information read from the two-dimensional code or barcode is stored in the item “body2”. In the case of ID authentication, it is assumed that the output target category is set to “0” in advance.

  Each item of the message in FIG. 10 is input at the timing shown in the “input timing” column in FIG. More specifically, the item whose input timing is “1” is input at the stage of step S10 in FIG. 7, and the item whose input timing is “2” is input at the stage of step S14. The item “3” is input in step S16. Note that the input timing column in FIG. 10 is illustrated for convenience of explanation, and the actual message does not include information on the input timing.

<When “Camera activation” button is clicked>
When the electronic medical record data is edited on the doctor terminal 70, an image (for example, an X-ray image) taken by the user with the portable terminal 60 may be desired to be pasted on the electronic medical record data. In this case, the user clicks the “camera activation” button in the function selection screen (FIG. 6B).

  In step S20 of FIG. 11A, since the input reception unit 22 is on standby until the “camera activation” button is clicked from the function selection screen, when the user clicks the “camera activation” button, the process proceeds to step S22. Transition.

  If transfering it to step S22, the process part 24 will judge whether the output destination (output object classification) is preset. When the determination at step S22 is affirmed, the processing unit 24 proceeds to step S28, but when the determination is negative, the processing unit 24 proceeds to step S24. Note that the case where the determination in step S22 is affirmed is a case where the position where the image is to be pasted is set in the electronic medical record data when the user selects “camera activation” in advance.

  When the determination in step S22 is negative and the process proceeds to step S24, the processing unit 24 displays the output destination selection screen (FIG. 12A) on the display unit 293 via the display control unit 20. In the output destination selection screen of FIG. 12A, buttons of “Paste to input location”, “S column”, “O column”, “A column”, and “P column” are displayed in a selectable manner. Yes. When “Paste in place of input” is selected, “Output target category” of the message is “0”, and “S column”, “O column”, “A column”, “P column” are selected. In this case, the “output target category” of the message is “1”, “2”, “3”, “4”.

  Next, in step S26, the input receiving unit 22 stands by until an output destination is selected on the output destination selection screen, and when selected, the process proceeds to step S28.

  In step S28, the processing unit 24 activates the camera 289. Then, in the next step S30, the processing unit 24 performs shooting using the camera 289 in accordance with a user operation. FIG. 12B shows the state of the mobile terminal 60 when the user has taken an X-ray image as an example.

  Next, in step S <b> 32, the processing unit 24 displays an edit presence / absence confirmation screen on the display unit 293 via the display control unit 20. Specifically, the processing unit 24 displays an edit presence / absence confirmation screen including “Yes” and “No” buttons as shown in FIG. The user selects “Yes” when he / she wants to hand draw a figure or the like on the captured image.

  In the next step S34, the processing unit 24 determines whether or not there is editing, that is, whether or not “Yes” is selected on the editing presence / absence confirmation screen. If the determination in step S34 is negative, the processing unit 24 proceeds to step S40. If the determination is affirmative, the processing unit 24 proceeds to step S36.

  When the process proceeds to step S <b> 36, the processing unit 24 displays an editing screen on the display unit 293 via the display control unit 20. This editing screen is a screen as shown in FIG. 12D, and is a screen on which figures and characters can be input by hand drawing. Note that the editing screen in FIG. 12D may be provided with a palette for changing the color and thickness of the hand-drawn line. When the hand-drawn editing is completed, the user presses an “end” button on the editing screen.

  Next, in step S38, the input receiving unit 22 waits until the editing is completed. That is, the input receiving unit 22 stands by until the “end” button is pressed on the editing screen. Then, when the “end” button is pressed by the user, the process proceeds to step S40.

  If transfering it to step S40, the process part 24 will shape | mold the message before transmission. The processing unit 24 delivers the formed electronic message to the electronic message transmission unit 28. Next, in step S <b> 42, the message transmission unit 28 transmits a message to the doctor terminal 70.

  Here, even if the edited image is an image as shown in FIG. 13A, the processing unit 24 uses the original image (original image (layer)) as shown in FIG. Assume that hand-drawn images (layers) as shown in (c) are transmitted separately. More specifically, the processing unit 24 generates original image data as shown in FIG. 14A and hand-drawn image data as shown in FIG.

  In the original image data of FIG. 14A and the hand-drawn image data of FIG. 14B, the items “processing date”, “processing time”, “terminal ID”, “processing classification”, “tool classification” , “Sequence ID” and “output target category” are stored in the same information. Among these items, “2” indicating image pasting is stored in the item “processing category”. In the item “output target category”, a number indicating a preset output destination or a selected output destination is stored. Note that the underlined number of the item “output target category” means that the number varies depending on the user's selection.

  On the other hand, regarding the “format type” in FIGS. 14A and 14B, the original image data in FIG. 14A is “1”, and the hand-drawn image data in FIG. 14B is “2”. It has become. However, since the sequence ID is common (001) in FIGS. 14 (a) and 14 (b), the data of FIGS. 14 (a) and 14 (b) is used to show the sequence ID in FIG. Such an image can be generated.

  Note that the item of input timing “1” shown in FIGS. 14A and 14B is input at the stage of step S20 in FIG. 11A, and the item of input timing “2”. Is input in the step S26. Further, the item of input timing “3” is input in the step S30, and the item of input timing “4” is input in the step S40.

  When the user does not perform hand-drawn editing, the hand-drawn image data in FIG. 14B is not generated, and only the original image data in FIG. 14A is generated.

<When the “Schema Input” button is clicked>
When editing electronic medical record data, the user may want to paste an electronic medical chart illustration image (schema image) on the electronic medical record data. In this case, the user clicks a “schema input” button in the function selection screen (FIG. 6B). Note that the processing in FIG. 11B is the same as that in FIG. 11A except for the processing indicated by the bold frame.

  In step S50 of FIG. 11B, since the input reception unit 22 is on standby until the “scheme input” button is clicked from the selection screen, when the user clicks the “schemas input” button, the process proceeds to step S52. To do.

  In steps S52, S54, and S56, the processing unit 24 and the input receiving unit 22 perform the same processes as those in steps S22, S24, and S26 described above.

  In step S58, the processing unit 24 displays a schema selection screen (FIG. 15) on the display unit 293 via the display control unit 20. In the next step S60, the input receiving unit 22 waits until the user selects a schema image on the schema selection screen. When the user selects a schema image, the process proceeds to step S62.

  Thereafter, the processes from step S62 to S72 are executed in the same manner as steps S32 to S42 in FIG. That is, when editing a schema image, the user can perform hand-drawn editing.

  FIG. 16A and FIG. 16B show an example of original image data and hand-drawn image data which are messages generated in schema input. The data in FIGS. 16A and 16B is that the item “tool classification” is “3 (schema input)” compared to the data in FIGS. 14A and 14B. They are different, and the data itself (the data of body1 itself) is different.

  Note that the item of input timing “1” shown in FIGS. 16A and 16B is input at the stage of step S50 in FIG. 11B, and the item of input timing “2”. Is input in the step S56. Further, the item of input timing “3” is input at the stage of step S60, and the item of input timing “4” is input at the stage of step S70.

  When the user does not perform hand-drawn editing on the schema image, only the original image data of FIG. 16A is generated without generating the hand-drawn image data of FIG. It has become.

<When the “Voice input” button is clicked>
When editing electronic medical record data, the user may want to paste information input by voice into the electronic medical record data. In this case, the user clicks the “voice input” button in the function selection screen (FIG. 6B). Note that the processing in FIG. 17 is the same as that in FIG. 11A except for the processing indicated by the bold frame.

  In step S80 of FIG. 17, the input receiving unit 22 is on standby until the “voice input” button is clicked from the function selection screen. When the user clicks the “voice input” button, the process proceeds to step S82.

  In steps S82, S84, and S86, the processing unit 24 and the input receiving unit 22 execute the same processes as those in steps S22, S24, and S26 (FIG. 11A) described above.

  Thereafter, when the process proceeds to step S88, the processing unit 24 displays a voice input screen (FIG. 18) on the display unit 293 via the display control unit 20. As an example, it is assumed that buttons for “input start” and “input end” are prepared on the voice input screen. The user clicks the “start input” button to start voice input.

  In step S90, the input reception unit 22 waits until receiving an instruction to start voice input, that is, until voice input is started. When the “input start” button is clicked by the user, the process proceeds to step S 92, where the processing unit 24 starts recognizing the voice input to the microphone 287, converts the voice to a character, and passes the display control unit 20. Displayed on the display unit 293.

  Next, in step S94, it is determined whether or not the input receiving unit 22 has received an instruction to end the voice input, that is, whether or not the “input end” button has been clicked. While the determination at step S94 is negative, the processing unit 24 repeatedly executes the process at step S92. Thereafter, when the “input end” button is clicked by the user, the process proceeds to step S96. Steps S96 and S98 are the same as steps S40 and S42 in FIG.

  FIG. 19 shows an example of voice input data that is a message generated by voice input. The data of FIG. 19 differs from the data of FIG. 10 in that the item “tool classification” is “4 (voice input)”, and the data itself (the data of body 2 itself) is different. 10 is different from FIG. 10 in that the value of the item “output target category” may be other than “0”.

  Note that the item of input timing “1” shown in FIG. 19 is input at the stage of step S80 in FIG. 17, and the item of input timing “2” is input at the stage of step S86. Further, the item of input timing “3” is input at the stage of step S92, and the item of input timing “4” is input at the stage of step S96.

<When the “Prescription Palette” button is clicked>
When editing electronic medical record data, the user may want to paste a prescription selected from a prescription palette (prescription selection screen) on which many prescription names are written in order to reduce the input burden. In this case, the user clicks the “Prescription Palette” button in the function selection screen (FIG. 6B).

  In step S102 of FIG. 20 (a), the input reception unit 22 is on standby until the “prescription palette” button is clicked from the function selection screen. Therefore, when the user clicks the “prescription palette” button, FIG. The process proceeds to step S104 of a).

  If transfering it to step S104, the process part 24 will display a prescription selection screen (FIG.21 (a)) on the display part 293 via the display control part 20. FIG. In addition, many prescriptions are displayed on the prescription selection screen in FIG. In the next step S106, the input receiving unit 22 waits until the user selects a prescription on the prescription selection screen. When the user selects a prescription, the process proceeds to step S108.

  If transfering it to step S108, the process part 24 will shape the message before transmission. Then, the processing unit 24 delivers the formed electronic message to the electronic message transmission unit 28. Next, in step S <b> 110, the message transmission unit 28 transmits a message to the doctor terminal 70. Thereafter, the process returns to step S102.

  FIG. 21B shows an example of prescription data, which is a message generated when a prescription is selected from the prescription palette. The data of FIG. 21B is different from the data of FIG. 10 in that the item “tool classification” is “5 (prescription pallet)”, and the data itself (the data of body 2 itself) is different. Yes. 10 is different from FIG. 10 in that the value of the item “output target category” is “5 (prescription column)”.

  It should be noted that the item of input timing “1” shown in FIG. 21B is input at the stage of step S102 in FIG. 20A, and the item of input timing “2” is input in step S106. Input in stages. The item of input timing “3” is input at the stage of step S108.

<When the “Disease Name Palette” button is clicked>
When editing electronic medical record data, the user may want to paste a disease name selected from a disease name palette (disease name selection screen) on which many names of disease names are written in the electronic medical record data in order to reduce the input burden. In this case, the user clicks a “disease name palette” button in the function selection screen (FIG. 6B).

  In step S112 of FIG. 20B, since the input reception unit 22 is on standby until the “disease name palette” button is clicked from the function selection screen, when the user clicks the “disease name palette” button, the process proceeds to step S114. Transition.

  In step S114, the processing unit 24 displays a disease name selection screen (FIG. 22A) on the display unit 293 via the display control unit 20. In addition, many disease names are displayed on the disease name selection screen in FIG. In the next step S116, the input receiving unit 22 waits until the user selects a disease name on the prescription selection screen. When the user selects a disease name, the process proceeds to step S118.

  If transfering it to step S118, the process part 24 will shape the message before transmission. Then, the processing unit 24 delivers the formed electronic message to the electronic message transmission unit 28. Next, in step S <b> 120, the message transmission unit 28 transmits a message to the doctor terminal 70. Thereafter, the process returns to step S112.

  FIG. 22B shows an example of disease name data that is a message generated when a disease name is selected from the disease name palette. The data of FIG. 22B is different from the data of FIG. 10 in that the item “tool classification” is “6 (disease name palette)”, and the data itself (the data of body 2 itself) is different. Yes. 10 is different from that of FIG. 10 in that the value of the item “output target category” is “6 (disease name column)”.

  Note that the item of input timing “1” shown in FIG. 22B is input at the stage of step S112 in FIG. 20B, and the item of input timing “2” is input in step S116. Input in stages. Also, the item of input timing “3” is input at the stage of step S118.

  As described above, in the mobile terminal 60, every time information such as an image or sound is input, a message corresponding to the input information is generated and transmitted to the doctor terminal 70.

(About processing of the doctor terminal 70)
Next, the process of the doctor terminal 70 when the portable terminal 60 is used as an input device will be described in detail with reference to the flowchart of FIG. The process of FIG. 23 is a process that is executed while the determination in step S304 of FIG. 4 is denied (from the start of editing electronic medical record data until a save request is issued).

  In the process of FIG. 23, first, in step S <b> 200, the input reception unit 30 stands by until a message is transmitted from the mobile terminal 60. When an electronic message is transmitted from the portable terminal 60, the process proceeds to step S202, and the input reception unit 30 receives the transmitted electronic message. The input receiving unit 30 passes the received electronic message to the electronic medical record data updating unit 36.

  Next, in step S204, the electronic medical record data update unit 36 analyzes the tool classification of the received electronic message.

<Tool category = ID authentication>
If the tool classification is “1” (ID authentication) as a result of the analysis in step S204, that is, if the message is ID authentication data as shown in FIG. 10, the process proceeds to step S206.

  In step S206, the electronic medical record data update unit 36 acquires the caret position (cursor position on the display unit 193). Next, in step S208, the electronic medical record data update unit 36 extracts the information stored in “body2” of the message (ID authentication data in FIG. 10), and in the data on the memory shown in FIG. The extracted information is stored at a position corresponding to the caret position. Thereafter, the process proceeds to step S222, and the electronic medical record data updating unit 36 updates and displays the electronic medical record data editing screen displayed on the display unit 193 with the data on the memory via the display control unit 34. To do. That is, the data received from the portable terminal 60 is input to a predetermined position on the electronic medical record data editing screen.

<Tool category = image pasting or schema input>
As a result of the analysis in step S204, when the tool classification is “2” (image pasting) or “3” (schema input), that is, the message is as shown in FIGS. 14 (a) and 14 (b). If it is data or data as shown in FIGS. 16A and 16B, the process proceeds to step S210.

  In step S210, the electronic medical record data updating unit 36 stores the data of “body1” of the original layer (for example, the data of FIG. 13B) on the memory (FIG. 5B) as the original image of the original layer. Store. Next, in step S212, the electronic medical record data updating unit 36 stores the data (for example, the data of FIG. 13C) of the hand-drawn layer whose sequence ID matches the original layer as the original image of the hand-drawn layer ( The data is stored on FIG. The electronic medical record data updating unit 36 omits the process of step S212 when only the original image data is received.

  Next, in step S214, the electronic medical record data update unit 36 creates a thumbnail image (for example, the data in FIG. 13A) using the original image of the original layer and the original image of the hand-drawn layer. If only the original image data is received, the electronic medical record data updating unit 36 sets the original image of the original layer as a thumbnail image.

  Next, in step S216, the electronic medical record data update unit 36 stores the thumbnail image on the memory based on the output target section. As shown in FIGS. 14A and 14B, if the output target section is “0”, the thumbnail image is stored at a position corresponding to the caret position on the memory. Thereafter, the process proceeds to step S222, and the electronic medical record data updating unit 36 updates and displays the electronic medical record data editing screen displayed on the display unit 193 with the data on the memory via the display control unit 34. To do. That is, the image received from the portable terminal 60 is input at a predetermined position on the electronic medical record data editing screen.

<Tool category = Voice input>
As a result of the analysis in step S204, if the tool classification is “4” (voice input), that is, if the message is voice input data as shown in FIG. 19, the process proceeds to step S218.

  In step S218, the electronic medical record data updating unit 36 stores the data of “body2” on the memory based on the output target section. As shown in FIG. 19, if the output target section is “0”, the data of “body2” is stored at a position corresponding to the caret position on the memory. Thereafter, in step S222, the electronic medical record data update unit 36 updates the electronic medical record data displayed on the display unit 193 with the data on the memory via the display control unit 34 and displays the updated data.

<Tool category = prescription palette or disease name palette>
As a result of the analysis in step S204, when the tool classification is “5” (prescription palette) or “6” (disease name palette), that is, the message is as shown in FIG. 21 (b) or FIG. 22 (b). If it is data, the process proceeds to step S220.

  If transfering it to step S220, the electronic medical record data update part 36 will store the data of "body2" on a memory (prescription column or disease name column). As shown in FIG. 21B, if the output target section is “5”, the data of “body2” is stored at the position corresponding to the prescription column on the memory. Further, as shown in FIG. 22B, if the output target category is “6”, the data of “body2” is stored at the position corresponding to the disease name column on the memory. Thereafter, the process proceeds to step S222, and the electronic medical record data updating unit 36 updates and displays the electronic medical record data displayed on the display unit 193 with the data on the memory via the display control unit 34.

  After the processing in FIG. 23 is executed as described above, the processing in FIG. 23 is repeatedly executed until the determination in step S304 in FIG. 4 is affirmed.

  Returning to FIG. 4, at the doctor terminal 70, the user edits the electronic medical record data (including input using the mobile terminal 60 described above as an input device), and when the editing is completed, the user inputs a save request. In this case, the input receiving unit 30 proceeds to step S306.

  In step S306, if the electronic medical record data is newly created, the storage processing unit 38 sets the version number to “1”, transmits the electronic medical record data to the server 10, and stores it. On the other hand, when the user edits the existing electronic medical record data, the storage processing unit 38 increments the version number by 1 (+1), transmits the electronic medical record data to the server 10 and stores it. . In this case, the edited electronic medical record data is managed as different data without being overwritten because the edition number is different from the electronic medical record data (existing electronic medical record data) before editing.

  Thus, in this embodiment, when the portable terminal 60 is used as an input device, the portable terminal 60 cannot store electronic medical record data. Thereby, when the portable terminal 60 is used as an input device, the electronic medical record data can be managed without increasing the version of the electronic medical record data more than necessary.

  In the menu screen of FIG. 6A, when the user selects “edit electronic medical record data”, the electronic medical record data can be edited on the portable terminal 60 in the same manner as the doctor terminal 70. In this case, when the edited electronic medical record data is stored, the version number is incremented by 1 (+1), and the electronic medical record data is transmitted to the server 10 and stored, similarly to the doctor terminal 70. In this case, the edited electronic medical chart data is managed as different data without being overwritten because the version number is different from the electronic medical chart data before editing.

  As described above in detail, according to the present embodiment, the display control unit 34 displays the electronic medical record data editing screen, and the mobile terminal 60 associated in advance with the editing screen displayed. When the information is input from the electronic medical record data, the electronic medical record data updating unit 36 inputs the information input at a designated position or a predetermined position of the electronic medical record data. Then, when an instruction to save the electronic medical record data after editing is input, the storage processing unit 38 assigns a new version number to the electronic medical record data after editing and stores it in the server 10. Thereby, in this embodiment, when the portable terminal 60 is used as an input device, the version number can be prevented from being increased as in the case where the electronic medical record data is edited and saved by the portable terminal 60. Therefore, when the electronic medical record data is edited by linking the doctor terminal 70 and the portable terminal 60, the electronic medical record data can be appropriately managed.

  In the present embodiment, the position where information is input can be set in advance in accordance with the type of information input from the mobile terminal 60. As a result, the position to be input by the user is set each time when it is determined that information must be input in a certain column depending on the type of information (in this embodiment, ID authentication data, prescription data, and disease name data). You do n’t have to. Thereby, a user's convenience can be improved.

  In the present embodiment, the electronic message transmitted from the mobile terminal 60 includes information on a position where information is input. Thereby, in the doctor terminal 70, the position which inputs information can be specified with reference to a message | telegram.

  In the present embodiment, since the electronic medical record data is stored in the server 10, the electronic medical record data can be shared among the plurality of doctor terminals 70 and the mobile terminals 60.

  In the above embodiment, the case where the electronic medical record data is stored in the server 10 has been described. However, the present invention is not limited thereto, and the electronic medical record data may be stored in the doctor terminal 70.

  In addition, although the said embodiment demonstrated the case where the doctor terminal 70 was PC, not only this but the doctor terminal 70 may be a smart phone and a tablet-type terminal.

  In the above-described embodiment, the case has been described in which either “electronic medical record editing” or “electronic medical record input” can be selected on the menu screen of FIG. 6A in the mobile terminal 60, but the present invention is not limited to this. Absent. That is, “electronic medical record editing” may not be performed on the mobile terminal 60.

  In the above embodiment, the case where information obtained from the touch panel 295, the microphone 287, and the camera 289 of the mobile terminal 60 is transmitted to the doctor terminal 70 and input to the electronic medical record data has been described, but the present invention is not limited to this. . That is, when the portable terminal 60 has another input device, information obtained from the other input device (for example, sensors such as a temperature sensor and a fingerprint sensor) is transmitted to the doctor terminal 70, and the electronic device It is good also as inputting into medical chart data.

  The above processing functions can be realized by a computer. In that case, a program describing the processing contents of the functions that the processing apparatus should have is provided. By executing the program on a computer, the above processing functions are realized on the computer. The program describing the processing contents can be recorded on a computer-readable storage medium (except for a carrier wave).

  When the program is distributed, for example, it is sold in the form of a portable storage medium such as a DVD (Digital Versatile Disc) or a CD-ROM (Compact Disc Read Only Memory) on which the program is recorded. It is also possible to store the program in a storage device of a server computer and transfer the program from the server computer to another computer via a network.

  The computer that executes the program stores, for example, the program recorded in the portable storage medium or the program transferred from the server computer in its own storage device. Then, the computer reads the program from its own storage device and executes processing according to the program. The computer can also read the program directly from the portable storage medium and execute processing according to the program. Further, each time the program is transferred from the server computer, the computer can sequentially execute processing according to the received program.

  The above-described embodiment is an example of a preferred embodiment of the present invention. However, the present invention is not limited to this, and various modifications can be made without departing from the scope of the present invention.

In addition, the following additional remarks are disclosed regarding description of the above embodiment.
(Appendix 1) Display the electronic medical record data editing screen on the computer display,
When information is input from another computer previously associated with the computer in a state where the editing screen is displayed on the display unit, the electronic medical record data is designated or predetermined. Enter the information in the location,
When an instruction to save the electronic medical record data to which the information is input is input in the computer, a new version number is given to the electronic medical record data to which the information is input, and the electronic medical record data is converted to the version number. And store it in the storage unit associated with the
An electronic medical record editing program for causing the computer to execute processing.
(Supplementary note 2) The electronic medical record editing according to supplementary note 1, wherein, in the process of inputting the information, the information is inputted at a position of electronic medical record data determined in advance corresponding to the type of the information. program.
(Supplementary Note 3) The information is selected from information of an image taken by the other computer, information based on the image, character information input to the other computer, and a plurality of information displayed on the other computer. The electronic medical record editing program according to appendix 1 or 2, characterized in that the electronic medical record editing program includes at least one of the information.
(Additional remark 4) The information of the position of the said electronic medical record data which inputs the said information with said information is input from said other computer, The electronic medical record edit program in any one of additional marks 1-3 characterized by the above-mentioned .
(Supplementary Note 5) The electronic medical record editing program according to any one of Supplementary Notes 1 to 4, wherein the storage unit is included in a device other than the device having the computer and the other computer.
(Appendix 6) Display the electronic medical record data editing screen on the computer display,
When information is input from another computer previously associated with the computer in a state where the editing screen is displayed on the display unit, the electronic medical record data is designated or predetermined. Enter the information in the location,
When an instruction to save the electronic medical record data to which the information is input is input in the computer, a new version number is given to the electronic medical record data to which the information is input, and the electronic medical record data is converted to the version number. And store it in the storage unit associated with the
An electronic medical record editing method, wherein the computer executes processing.
(Appendix 7) A display control unit that displays an electronic medical record data editing screen on the display unit;
When information is input from another computer associated in advance in a state where the editing screen is displayed on the display unit, the electronic medical record data is designated at a specified position or a predetermined position. An updater for entering information,
Upon receiving an instruction to save the electronic medical record data to which the information has been input, a new version number is assigned to the electronic medical record data to which the information has been input, and the electronic medical record data is stored in association with the version number. A storage processing unit for storing in the storage unit;
An information processing apparatus comprising:
(Supplementary note 8) The information processing apparatus according to supplementary note 7, wherein the update unit inputs the information at a position of electronic medical record data determined in advance corresponding to the type of the information.
(Supplementary Note 9) The information is selected from information of an image taken by the other computer, information based on the image, character information input to the other computer, and a plurality of information displayed on the other computer. The information processing apparatus according to appendix 7 or 8, wherein the information processing apparatus includes at least one of the information.
(Supplementary note 10) The information processing apparatus according to any one of supplementary notes 7 to 9, wherein information on a position of the electronic medical record data for inputting the information is inputted together with the information from the other computer.
(Supplementary Note 11) The information processing apparatus according to any one of Supplementary notes 7 to 10, wherein the storage unit is included in a device other than the information processing device and the other computer.

10 Server 34 Display Control Unit 36 Electronic Medical Record Data Update Unit (Update Unit)
38 Storage Processing Unit 60 Mobile Terminal (Other Computer)
70 Doctor terminal (information processing device, computer)
193 Display

Claims (7)

Display the electronic medical record data editing screen on the computer display,
When information is input from another computer previously associated with the computer in a state where the editing screen is displayed on the display unit, the electronic medical record data is designated or predetermined. Enter the information in the location,
When an instruction to save the electronic medical record data to which the information is input is input in the computer, a new version number is given to the electronic medical record data to which the information is input, and the electronic medical record data is converted to the version number. And store it in the storage unit associated with the
An electronic medical record editing program for causing the computer to execute processing.   2. The electronic medical record editing program according to claim 1, wherein in the process of inputting the information, the information is input at a position of electronic medical record data determined in advance corresponding to the type of the information.   The information includes information on an image captured by the other computer, information based on the image, character information input to the other computer, and information selected from a plurality of information displayed on the other computer. The electronic medical record editing program according to claim 1, comprising at least one.   The electronic medical record editing program according to any one of claims 1 to 3, wherein information on a position of the electronic medical record data for inputting the information is input from the other computer together with the information.   The electronic medical record editing program according to any one of claims 1 to 4, wherein the storage unit is included in an apparatus other than the apparatus including the computer and the other computer. Display the electronic medical record data editing screen on the computer display,
When information is input from another computer previously associated with the computer in a state where the editing screen is displayed on the display unit, the electronic medical record data is designated or predetermined. Enter the information in the location,
When an instruction to save the electronic medical record data to which the information is input is input in the computer, a new version number is given to the electronic medical record data to which the information is input, and the electronic medical record data is converted to the version number. And store it in the storage unit associated with the
An electronic medical record editing method, wherein the computer executes processing. A display control unit for displaying an electronic medical record data editing screen on the display unit;
When information is input from another computer associated in advance in a state where the editing screen is displayed on the display unit, the electronic medical record data is designated at a specified position or a predetermined position. An updater for entering information,
Upon receiving an instruction to save the electronic medical record data to which the information has been input, a new version number is assigned to the electronic medical record data to which the information has been input, and the electronic medical record data is stored in association with the version number. A storage processing unit for storing in the storage unit;
An information processing apparatus comprising:

Images