JP2020170549A - Electronic medical chart system and electronic medical chart program - Google Patents

Abstract

To provide an electronic medical chart device and an electronic medical chart program which can indicate by whom and when each medical chart information therein was recorded.SOLUTION: The electronic medical chart device includes: a description processing unit for sequentially describing plural pieces of medical chart information into an electronic medical chart in response to operations by users; an acquisition processing unit for acquiring, every time the description processing unit describes medical chart information into the electronic medical chart, information on a person who recorded the medical chart information, the information including information for identifying the person who recorded medical chart information and information on when the medical chart information was recorded; and a storage processing unit for relating the information acquired by the acquisition processing unit to the chart information and storing both the information into a storage unit.SELECTED DRAWING: Figure 7

Description

The present invention relates to an electronic medical record system and an electronic medical record program.

In recent years, medical institutions such as hospitals have used an electronic medical record system (see, for example, Patent Document 1) that manages medical information related to patient medical care with electronic data called an electronic medical record. Input to the electronic medical record can be performed using, for example, a keypad displayed on the touch panel display.

Japanese Patent No. 4811383

By the way, in electronic medical records, it is required to clarify the responsibility for creation, that is, when and who created it from the perspective of a third party. Therefore, in the electronic medical record system, it is general that the user (for example, a doctor) who finally saved the electronic medical record and the date and time of the saving are recorded.

However, if only the user who finally saved the electronic medical record and the date and time when the electronic medical record was saved are recorded, a plurality of information (for example, a doctor, a clerk, a nurse, and an associate nurse) can be used in the electronic medical record. When (medical record information) is listed in sequence, it is unknown when and who entered the individual medical record information.

An object of the present invention is to provide an electronic medical record system and an electronic medical record program that can tell when and who described individual medical record information described in an electronic medical record.

The electronic medical record system according to the present invention includes a description processing unit that describes medical record information in the electronic medical record in response to a user operation, and each time new medical record information is added to the same electronic medical record by the description processing unit. The acquisition processing unit that acquires the writer information including the writer identification information indicating the writer of the information and the description date and time information indicating the description date and time of the medical record information, and the writer information acquired by the acquisition processing unit. It is provided with a storage processing unit that is associated with the new medical record information and stored in the storage unit.

The electronic medical record program according to the present invention includes a description processing step in which the medical record information is described in the electronic medical record in response to a user operation, and each time new medical record information is added to the same electronic medical record in the description processing step. The acquisition process step for acquiring the writer information including the writer identification information indicating the writer of the information and the description date and time information indicating the description date and time of the medical record information, and the writer information acquired in the acquisition process step. This is an electronic medical record program for causing the processor to execute a storage processing step that is associated with the new medical record information and stored in the storage unit.

According to the present invention, there is provided an electronic medical record system and an electronic medical record program that show when and who wrote the individual medical record information described in the electronic medical record.

FIG. 1 is a diagram showing a configuration of an electronic medical record system according to an embodiment of the present invention. FIG. 2 is a diagram showing an example of an account management screen displayed on the electronic medical record system according to the embodiment of the present invention. FIG. 3 is a diagram showing an example of an account management master used in the electronic medical record system according to the embodiment of the present invention. FIG. 4 is a diagram showing an example of a medical record screen displayed by the electronic medical record system according to the embodiment of the present invention. FIG. 5 is a diagram showing an example of a medical record screen displayed by the electronic medical record system according to the embodiment of the present invention. FIG. 6 is a diagram showing an example of XML information used in the electronic medical record system according to the embodiment of the present invention. FIG. 7 is a diagram showing an example of a medical record screen displayed by the electronic medical record system according to the embodiment of the present invention. FIG. 8 is a diagram showing an example of an electronic medical record processing executed by the electronic medical record system according to the embodiment of the present invention.

Hereinafter, embodiments of the present invention will be described with reference to the accompanying drawings for the purpose of understanding the present invention. It should be noted that the following embodiments are examples that embody the present invention, and do not limit the technical scope of the present invention.

[Electronic medical record system 1]
As shown in FIG. 1, the electronic medical record system 1 according to the embodiment of the present invention includes an electronic medical record device 10, one or more client terminals 20, and a printer 30. The electronic medical record device 10, the client terminal 20, and the printer 30 can communicate with each other via a network 40 such as a LAN or the Internet.

[Electronic medical record device 10]
The electronic medical record device 10 is a computer including a control unit 11, a storage unit 12, a display unit 13, an operation unit 14, a communication IF 15, a drive device 16, and the like. The electronic medical record device 10 is provided inside or outside a medical institution such as a hospital or a pharmacy in which the electronic medical record device 10 is used. That is, the electronic medical record device 10 may be provided outside the medical institution, and the client terminal 20 may be provided in the medical institution.

The electronic medical record device 10 has an electronic medical record editing function capable of executing editing processing such as writing and updating information (medical record information) in the electronic medical record including medical information of a patient in response to an operation of the client terminal 20. To be equipped. Further, the electronic medical record device 10 may have a function of a receipt computer processing system capable of executing accounting processing such as registration and updating of accounting information according to an operation of the client terminal 20.

The control unit 11 includes a CPU, a ROM, a RAM, and a control device such as an EEPROM (registered trademark). The CPU is a processor that executes various arithmetic processes. The ROM is a non-volatile storage unit in which information such as a control program for causing the CPU to execute various processes is stored in advance. The RAM is a volatile storage unit, and the EEPROM is a non-volatile storage unit. The RAM and the EEPROM are used as temporary storage memories (work areas) for various processes executed by the CPU. Then, the control unit 11 uses the CPU to execute various processes according to various control programs stored in advance in the ROM, the EEPROM, or the storage unit 12.

The storage unit 12 is a non-volatile storage unit such as a hard disk drive, SSD (Solid State Drive), or a flash memory that stores various control programs and various data executed by the control unit 11. Specifically, the storage unit 12 has storage areas such as a program area 121, a master area 122, and a data area 123.

In the program area 121, an electronic medical record program for causing the control unit 11 to execute various processes such as an electronic medical record process (see FIG. 8) described later is stored. An application program such as an operating system (OS) and browser software is also stored in the program area 121.

The account management master D1 is stored in the master area 122. The account management master D1 is used for user authentication when logging in to the electronic medical record system 1. The account management master D1 is appropriately edited and stored in the master area 122 according to a user operation of the electronic medical record device 10 or the client terminal 20 at the time of initial setting or maintenance of the electronic medical record device 10. ..

Here, FIG. 2 is an example of the account management screen P1 for editing the account management master D1. On the account management screen P1, information about the user who uses the electronic medical record system 1 can be edited. In FIG. 2, Clark A is selected from a plurality of users registered in the account management master D1, and various information related to Clark A can be edited. The “proxy input authority” shown in FIG. 2 is the authority for a proxy operation to act for a doctor's operation (input operation for an electronic medical record). The target doctors to be represented can be selected from the drop-down list. In the example shown in FIG. 2, Clark A is given the proxy input authority to perform the proxy operation of Doctor A. As a result, Clark A can describe the medical record information (for example, medical record information B1 to B21 shown in FIG. 5) described later in the electronic medical record as a substitute for the doctor A (doctor office work assistant).

FIG. 3 is an example of user data registered in the account management master D1. As shown in FIG. 3, information such as a user ID, a user name, a password, a proxy input authority, a target doctor, and a qualification is registered in the account management master D1 for each user. The user ID and user name are examples of identification information for identifying a user. The password is used for user authentication when logging in to the electronic medical record system 1. The qualification indicates the qualification held by the user. On the account management screen P1 shown in FIG. 2, the authority related to the electronic medical record can be set individually for each qualification. For example, doctors are authorized to view, modify, and save electronic medical records, nurses are authorized to view and modify electronic medical records, and clerks are authorized to view electronic medical records. .. However, a user who has the authority to input on behalf of the user is given the same authority as the target doctor regardless of the qualification of the user.

Although not shown, other master information such as a disease name master, a patient master, and a drug master is also stored in the master area 122.

Information such as XML information D2 (see FIG. 6) and medical record database D3 is stored in the data area 123. The XML information D2 describes the medical record information (that is, information indicating the content of medical practice and the like) described in the electronic medical record by using XML (Extensible Markup Language). The XML information D2 is created according to a user operation such as a doctor using the client terminal 20, and is updated at any time. In addition to the medical record information, the XML information D2 also includes the writer information described later (for example, the writer information W1 to W21 shown in FIG. 7).

The medical record database D3 is a database for accumulating the medical record information described in the electronic medical record and storing it for a long period of time. For example, when a user such as a doctor using the client terminal 20 performs a medical record information storage operation at the end of a medical examination, the medical record information and the writer information included in the XML information D2 are converted into the medical record database D3. It is saved in.

In addition, any one or more of the account management master D1, the XML information D2, and the medical record database D3 may be stored in a storage device provided outside the electronic medical record device 10. For example, the electronic medical record system 1 may include a server device that stores any one or more of the account management master D1, the XML information D2, and the medical record database D3. Then, the control unit 11 may be able to access the server device via the Internet or the like.

The display unit 13 is a display unit such as a liquid crystal display or an organic EL display that displays various information according to a control instruction from the control unit 11. The operation unit 14 is an operation unit operated by a user to input various information into the electronic medical record device 10. Specifically, the operation unit 14 includes a keyboard and a mouse (pointing device) that accept input operations on various operation screens displayed on the display unit 13. Further, the operation unit 14 may include a touch panel that accepts touch operations on various operation screens displayed on the display unit 13, or a voice input device that accepts input of various information by voice recognition.

The communication IF 15 is a communication having a network card or the like that executes data communication wirelessly or by wire according to a predetermined communication protocol between the client terminal 20 and an external device such as the printer 30 via the network 40. It is an interface.

The drive device 16 can read information such as the electronic medical record program from a computer-readable recording medium 161 on which the electronic medical record program or the like is recorded. The recording medium 161 is a CD, DVD, BD, USB memory, or the like, and the drive device 16 is a CD drive, a DVD drive, a BD drive, a USB port, or the like. Then, in the electronic medical record device 10, the electronic medical record program read from the recording medium 161 by the control unit 11 using the drive device 16 is stored in the program area 121.

Then, in the electronic medical record device 10 configured in this way, the control unit 11 is a description processing unit 111, an acquisition processing unit 112, a storage processing unit 113, a display control unit 114, an update processing unit 115, and a print control unit. Includes 116. Specifically, the control unit 11 executes various processes according to the electronic medical record program, so that in the electronic medical record device 10, the control unit 11 has the description processing unit 111, the acquisition processing unit 112, and the storage processing unit. It functions as 113, a display control unit 114, an update processing unit 115, and a print control unit 116.

The description processing unit 111 can sequentially describe a plurality of the chart information in the electronic medical record according to a user operation such as a doctor using the client terminal 20. The description of the medical record information in the electronic medical record can be performed, for example, through the medical record screen P2.

Here, FIG. 4 is a diagram showing an example of a medical record screen P2 displayed on the electronic medical record device 10 or the client terminal 20. As shown in FIG. 4, the chart screen P2 includes display areas A1 to A5.

In the display area A1, electronic medical records created in the past can be displayed. In the display area A2, the electronic medical record that is the current editing target can be displayed. Patient information is displayed in the display area A3. Further, a keypad used for editing an electronic medical record is displayed in the display area A4. Further, a shortcut key or the like used for editing the electronic medical record is displayed in the display area A5.

Here, FIG. 5 shows an example of an electronic medical record displayed in the display area A2 of the medical record screen P2. In the electronic medical record shown in FIG. 5, a plurality of medical record information B1 to B21 have already been described.

In the electronic medical record device 10, a plurality of methods are prepared as a method for describing the medical record information in the electronic medical record. For example, the medical record information can be described in the electronic medical record by selecting a desired area of the electronic medical record with a mouse or a touch panel and then inputting a character string from the keyboard. Further, the medical record information can be described in the electronic medical record by operating the keypad displayed in the display area A4 with a mouse, a numeric keypad, or a touch panel. Further, by registering arbitrary medical record information as set information in advance and selecting the set information with a mouse, a numeric keypad, or a touch panel, the medical record information can be described in the electronic medical record. Further, the medical record information can be described in the electronic medical record by dragging and dropping the icon indicating the set information to the desired area of the electronic medical record displayed in the display area A2.

In addition, a plurality of users can sequentially describe the medical record information for the same electronic medical record (that is, the electronic medical record of the same patient on the same date). For example, after Doctor A describes the medical record information for the electronic medical record, Clark A and Doctor B can sequentially add new medical record information to the same electronic medical record.

By the way, in electronic medical records, it is required to clarify the responsibility for creation, that is, when and who created it from the perspective of a third party. Therefore, in the electronic medical record device, it is general that the user (for example, a doctor) who finally saved the electronic medical record and the storage date and time thereof are recorded. However, if only the user who finally saved the electronic medical record and the date and time of the saving are recorded, the medical record information is stored in the electronic medical record by a plurality of users (for example, a doctor, a clerk, a nurse, and an associate nurse). When are listed in sequence, it is not possible to know which medical record information was entered when and who entered it. On the other hand, in the electronic medical record device 10 according to the present embodiment, it is possible to know when and who described the individual medical record information described in the electronic medical record by the configuration described below.

Each time the medical record information is described in the electronic medical record by the description processing unit 111, the acquisition processing unit 112 indicates a writer identification information indicating the person who wrote the medical record information and a description date and time indicating the description date and time of the medical record information. It is possible to obtain writer information including information. The writer identification information is, for example, a user ID or a user name corresponding to a logged-in user. The acquisition processing unit 112 acquires the writer identification information from, for example, the account management master D1. As the described date and time information, for example, the time synchronized between the electronic medical record device 10 and the client terminal 20 can be used. Alternatively, the time (time stamp) acquired from an arbitrary time server on the Internet may be used as the described date and time information.

When the medical record information is described in the electronic medical record by inputting a character string or a sentence from the keyboard, the character string or the sentence input from the keyboard is once displayed in the text box, and then finally. When the confirmation button is operated, it is described in the electronic medical record as the medical record information. Then, the writer information corresponding to the medical record information is acquired by the acquisition processing unit 112. In this case, for example, the date and time when the confirmation button is operated is acquired as the described date and time information.

Further, when the medical record information is described in the electronic medical record by selecting the set information, the medical record information registered in advance corresponding to the set information is described at the time when the set information is selected. Described in the electronic medical record. Then, the writer information corresponding to the medical record information is acquired by the acquisition processing unit 112. In this case, for example, the date and time when the set information is selected is acquired as the described date and time information.

In addition, when the medical record information is described in the electronic medical record by the description processing unit 111 in response to the proxy operation by the second user who substitutes the operation of the first user, the acquisition processing unit 112 is the first user. And the identification information of both the second user is acquired as the description person identification information. For example, when the medical record information is described in the electronic medical record by the description processing unit 111 in response to the proxy operation by the above-mentioned Clark A (see FIGS. 2 and 3), the acquisition processing unit 112 performs the proxy operation. The identification information of the doctor A who is the target doctor and the identification information of the Clark A who is the agent are acquired as the description information.

The storage processing unit 113 can store the writer information acquired by the acquisition processing unit 112 in the storage unit 12 in association with the medical record information. Specifically, the storage processing unit 113 associates the writer information acquired by the acquisition processing unit 112 with the medical record information each time the medical record information is described in the electronic medical record by the description processing unit 111. Then, it is stored in the storage unit 12 as the XML information D2.

Here, FIG. 6 shows a part of the XML information D2 stored in the storage unit 12 by the storage processing unit 113. As shown in FIG. 6, in the XML information D2, the writer information W11 is associated with the medical record information B11 and stored, and the writer information W12 is associated with the medical record information B12 and stored.

In the writer information W11 shown in FIG. 6, the user ID of the writer of the medical record information B11 is "002", the user name of the writer of the medical record information B11 is "doctor A", and the medical record. It is shown that the description date and time of the information B11 is 19:42:12 on July 6, 2016. Further, the description person information W11 indicates that the medical record information B11 is not described by a proxy operation because the values of the "ProxyUserID" and the "ProxyUserName" are empty.

In the writer information W12 shown in FIG. 6, the user ID of the writer of the medical record information B12 is "005", the user name of the writer of the medical record information B12 is "Clark A", and the medical record. Information B12 is described by proxy operation, the user ID and user name of the target doctor are "002" and "Doctor A", and the description date and time of the medical record information B12 is July 6, 2016. 19:45:27 ”.

The display control unit 114 can cause the display unit 13 or the display unit 23 to display the writer information associated with the medical record information together with a plurality of the medical record information described in the electronic medical record. For example, the display control unit 114 may display the writer information associated with the medical record information adjacent to the medical record information. The display control unit 114 displays the medical record information and the writer information on the display unit 13 or the display unit 114 based on the medical record information included in the XML information D2 and the writer information corresponding to the medical record information. It is displayed on the display unit 23.

Here, FIG. 7 shows an example of an electronic medical record displayed in the display area A2 by the display control unit 114. In the example shown in FIG. 7, the corresponding writer information W1 to W21 are displayed adjacent to each of the medical record information B1 to B21. As a result, when and who wrote each medical record information is displayed in an easy-to-understand manner.

When the writer information includes the identification information of the target doctor as in the writer information W12 shown in FIG. 6, the display control unit 114 may use the writer information W12 shown in FIG. 7, for example. The above-mentioned writer information is displayed so that both the agent and the target doctor can be understood. In the writer information W12 shown in FIG. 7, "Doctor A (substitute: Clark A)" is displayed, and it is clearly stated that Clark A has described the medical record information B12 as a substitute for the doctor A.

When the writer information is not associated with the medical record information for some reason such as a difference in the version of the electronic medical record program, the display control unit 114 may use the writer information W15 shown in FIG. 7, for example. It may be displayed that the writer information is not associated with the above.

The display control unit 114 can display the chart information in a display mode selected at any time according to a user operation from a plurality of display modes including a first display mode and a second display mode. Is. The first display mode is a display mode in which only the medical record information among the medical record information and the writer information is displayed on the display unit 13 or the display unit 23, as in the display example shown in FIG. 5, for example. .. The second display mode is a display mode in which both the medical record information and the writer information are displayed on the display unit 13 or the display unit 23, as in the display example shown in FIG. 7, for example.

The display control unit 114 can switch the display mode according to a predetermined display mode switching operation by the user. For example, the display control unit 114 may sequentially switch the display mode each time the header area (the area displayed as “current chart” in FIG. 5) in the display area A2 is left-clicked with the mouse. Good. As a result, the user can immediately switch to the desired display mode with a simple operation.

In the second display mode, the display control unit 114 may display the writer information in a display mode different from the medical record information. For example, the medical record information may be displayed in a relatively conspicuous color (for example, a dark color such as black), and the writer information may be displayed in a relatively inconspicuous color (for example, a light color such as gray). .. Alternatively, the medical record information may be displayed in relatively large characters, and the writer information may be displayed in relatively small characters. As a result, in the second display mode, the medical record information and the writer information can be easily distinguished, so that the visibility of the medical record information is lowered due to the display of the writer information, and the cause thereof. It is possible to suppress oversight of the medical record information.

In the second display mode, the display control unit 114 may display only one of the description person identification information and the description date and time information included in the description person information. Alternatively, the display control unit 114 has a display mode for displaying both the description person identification information and the description date and time information included in the description person information, and the description of the description person identification information and the description date and time information. The display mode for displaying only the person identification information and the display mode for displaying only the description date and time information among the description person identification information and the description date and time information may be sequentially switched according to the user operation.

The update processing unit 115 can update the medical record information described in the electronic medical record according to a user operation. For example, when any of the medical record information displayed in the display area A2 is selected as an update target by, for example, a double-click operation of the mouse, a text box displaying the medical record information is displayed and a keyboard is displayed. It is possible to change the medical record information by. After that, when the confirmation button is finally operated, the medical record information is updated.

When the medical record information is updated by the update processing unit 115, the acquisition processing unit 112 acquires the identification information of the updater of the medical record information and the update date and time of the medical record information as the description person identification information. For example, the date and time when the confirmation button is operated is acquired as the described date and time information. The writer information acquired by the acquisition processing unit 112 is stored in the storage unit 12 in association with the medical record information by the storage processing unit 113. At this time, the writer information corresponding to the medical record information before the update may be overwritten by the writer information corresponding to the medical record information after the update, or may be retained without being overwritten. The display control unit 114 causes the display unit 13 or the display unit 23 to display the latest writer information associated with the medical record information together with the medical record information.

The print control unit 116 can have the printer 30 print the writer information associated with the medical record information together with the medical record information described in the electronic medical record. The printer 30 is an example of the "printing unit" of the present invention.

The print control unit 116 causes the printer 30 to print the medical record information in a print mode selected according to a user operation from a plurality of print modes including a first print mode and a second print mode. Is possible. The first print mode is a print mode in which the printer 30 prints only the medical record information among the medical record information and the writer information. That is, the first print mode is a print mode corresponding to the first display mode. The second print mode is a print mode in which the printer 30 prints both the medical record information and the writer information. That is, the second print mode is a print mode corresponding to the second display mode.

As a method of selecting the print mode, for example, a method of setting a print mode of either the first print mode or the second print mode in advance from a setting screen or the like can be considered. Alternatively, a dialog box in which the print mode can be selected may be displayed when a predetermined print operation is performed by the user. Further, depending on the display mode (the first display mode or the second display mode) at the time when the print operation is performed, the print mode corresponding to the display mode (the first print mode or the second display mode). Print mode) may be selected automatically.

In the present embodiment, the medical record information is stored as the XML information D2 in a state of being grouped together for each of the predefined blocks.

For example, with respect to medical record information related to inspection results (hereinafter referred to as “inspection result information”), a plurality of inspection result information having a common inspection date are collected in one block and stored as the XML information D2. Specifically, in the XML information D2, a plurality of inspection result information having a common inspection date is inserted between a start tag and an end tag indicating that the block is related to the inspection result. Therefore, in a state where the inspection result information on a certain inspection date (hereinafter referred to as "first inspection result information") is already stored as the XML information D2, new inspection result information on the same inspection date (hereinafter, referred to as "first inspection result information"). When "second test result information") is stored, these two test result information are collected in one block and stored as the XML information D2. As a result, these two inspection result information are displayed as one block in the display area A2. In the present embodiment, the storage processing unit 113 stores the writer information acquired by the acquisition processing unit 112 in the storage unit 12 for each block. Therefore, the block in which the first inspection result information and the second inspection result information are put together is associated with the description person of the second inspection result information and the description person information indicating the description date and time. As a result, in the second display mode, the writer information of the first inspection result information is not displayed, and the writer information of the second inspection result information is displayed.

Further, for example, with respect to medical record information related to medication (hereinafter referred to as “medication information”), a plurality of medication information having a common usage and administration days are collected in one block and stored in the XML information D2. Therefore, in a state where the medication information of the usage and administration days (hereinafter referred to as "first medication information") is already stored as the XML information D2, new medication information of the same usage and administration days (hereinafter, "" When the "second medication information") is stored, these two medication information are collected in one block and stored as the XML information D2. As a result, these two medication information are displayed as one block in the display area A2. Then, in the second display mode, the writer information of the first medication information is not displayed, and the writer information of the second medication information is displayed.

As described above, in the present embodiment, when a plurality of medical record information is collected in one block, not all the writer information corresponding to the plurality of medical record information is stored, but the medical record with the latest description date and time. Only information is stored. Therefore, the increase in the file size of the XML information D2 due to the storage of all the writer information corresponding to the plurality of medical record information is suppressed. In addition, as another embodiment, when a plurality of medical record information is collected in one block, all the writer information corresponding to the plurality of medical record information may be stored.

Further, in the present embodiment, when a plurality of medical record information is collected in one block, not all the writer information corresponding to the plurality of medical record information is displayed, but only the medical record information having the latest description date and time. Is displayed. Therefore, in the second display mode, the deterioration of the visibility of the medical record information due to the display of all the writer information corresponding to the plurality of medical record information is suppressed. As another embodiment, when a plurality of medical record information is collected in one block, all the writer information corresponding to the plurality of medical record information may be displayed.

It should be noted that "a plurality of medical record information is stored together in one block" does not necessarily mean that the plurality of medical record information is stored adjacent to or close to each other, and the control unit 11 stores the plurality of medical record information. It is sufficient if the block is stored in a recognizable state. For example, the plurality of medical record information may be stored in association with each other.

It should be noted that the definition of the block (that is, the condition for collecting a plurality of medical record information) may be changed, added, or deleted according to the user operation. Further, the block may be divided into a plurality of blocks according to a user operation. Further, a plurality of the blocks may be combined into one block according to a user operation. For example, when the cursor moves to another area, when another item is selected, or when a line break occurs while the user is performing an input operation on an input area where arbitrary information can be input. , Or, when a delimiter operation is performed such as when the Tab key is operated, it is conceivable that the writer information is acquired and associated with each other and stored. In this case, after that, when the cursor is returned to the input area and the input is continued, when the line feed is deleted and the input is continued, the space input by the operation of the Tab key is deleted and the input is input. If is continued, the input contents up to that point are combined as one block when the delimiter operation is performed thereafter, and the writer information corresponding to the block is acquired and stored in association with each other. Can be considered. In addition, when a plurality of medication information having a common usage and administration days are regarded as one prescription order, a group of a plurality of prescription orders may be included in the definition of the block. For example, when the information of the first prescription order such as the usage and the number of administration days for the drug A is input, the writer information corresponding to the information of the first prescription order is acquired, and then the drug A for the drug B is obtained. When the information of the second prescription order having the same usage and administration days is input, the combination of the first prescription order and the second prescription order is judged as one block, and the above-mentioned person corresponding to the block. It is conceivable that the information is acquired and stored in association with the block.

[Client terminal 20]
On the other hand, as shown in FIG. 1, the client terminal 20 is a computer including a control unit 21, a storage unit 22, a display unit 23, an operation unit 24, a communication IF 25, a drive device 26, and the like. The client terminal 20 is provided in a hospital clinic, a dispensing room where dispensing is performed, a ward where patients are hospitalized, an accounting counter, and the like, and is used by medical staff such as doctors, pharmacists, nurses, and clerks. It is an operation terminal.

The control unit 21 includes control devices such as a CPU, ROM, RAM, and EEPROM. The CPU is a processor that executes various arithmetic processes. The ROM is a non-volatile storage unit in which information such as a control program for causing the CPU to execute various processes is stored in advance. The RAM is a volatile storage unit, and the EEPROM is a non-volatile storage unit. The RAM and the EEPROM are used as temporary storage memories (work areas) for various processes executed by the CPU. Then, the control unit 21 uses the CPU to execute various processes according to various control programs stored in the ROM, the EEPROM, or the storage unit 22 in advance.

The storage unit 22 is a non-volatile storage unit such as a hard disk, SSD, or flash memory that stores various control programs and various data executed by the control unit 21. Specifically, the storage unit 22 stores application programs such as an operating system (OS) and browser software. The browser software displays various operation screens and the like on the display unit 23 by accessing the electronic medical record device 10 via the network 40, and also performs an input operation using the operation unit 24 on the operation screen. This is application software for transmitting to the electronic medical record device 10. Specifically, when the control unit 21 inputs address information such as a URL (Universal Resource Locator) corresponding to the electronic medical record device 10 at a predetermined position on the operation screen displayed by the browser software, the control unit 21 said. The electronic medical record device 10 is accessed based on the address information.

The display unit 23 is a display unit such as a liquid crystal display or an organic EL display that displays various information according to a control instruction from the control unit 21. The operation unit 24 is an operation unit operated by a user to input various information to the client terminal 20. Specifically, the operation unit 24 includes a keyboard and a mouse (pointing device) that accept input operations on various operation screens displayed on the display unit 23. Further, the operation unit 24 may include a touch panel that accepts touch operations on various operation screens displayed on the display unit 23, or a voice input device that accepts input of various information by voice recognition.

The communication IF 25 is a communication interface having a network card or the like that executes data communication wirelessly or by wire according to a predetermined communication protocol with an external device such as the electronic medical record device 10 via the network 40. ..

The drive device 26 can read information about the OS or the browser software from a computer-readable recording medium 261 on which the OS or the browser software is recorded. The recording medium 261 is a CD, DVD, BD, USB memory, or the like, and the drive device 26 is a CD drive, a DVD drive, a BD drive, a USB port, or the like.

Then, in the electronic medical record system 1, a server client system is configured by the electronic medical record device 10 and the client terminal 20, and the electronic medical record device 10 displays and records various information according to a user operation of the client terminal 20. And processing such as printing is executed. That is, the display, operation, selection, input, and the like described below may be performed on the display unit 13, the operation unit 14, the display unit 23, the operation unit 24, and the like of the electronic medical record device 10. It is done using.

[Electronic medical record processing]
Here, FIG. 8 is a flowchart showing an example of the procedure of electronic medical record processing executed by the control unit 11. The electronic medical record processing is started in response to the start of execution of the electronic medical record program in the electronic medical record device 10.

<Step S11>
In step S11, the control unit 11 performs a login process. Specifically, the control unit 11 displays a login screen for inputting a user name and a password in response to a login operation by the user (for example, an operation of a login button). Then, the control unit 11 collates the input user name and password with the user information registered in the account management master D1 to perform user authentication.

<Step S12>
In step S12, the control unit 11 displays the chart screen P2 in response to a user operation. For example, the control unit 11 displays a medical record screen P2 corresponding to the electronic medical record of the patient in response to the selection of any patient from the patients listed on the consultation list screen (not shown). indicate.

<Step S13>
In step S13, the control unit 11 (the description processing unit 111) determines whether or not a description operation for writing new medical record information in the electronic medical record has been performed. Then, when it is determined that the described operation has been performed (S13: Yes), the control unit 11 shifts the process to step S14, and determines that the described operation has not been performed (S13: No). ), The process is shifted to step S16. The described operations include, for example, a character string input operation using a keyboard, an input operation using the keypad, and a drag-and-drop operation using a mouse.

<Step S14>
In step S14, the control unit 11 (the acquisition processing unit 112) has the writer information (that is, the writer identification information and the description date and time information) corresponding to the medical record information newly described in the electronic medical record. To get. Specifically, the control unit 11 acquires the user ID and user name of the logged-in user as the description person identification information, and acquires the current time as the description date and time information.

<Step S15>
In step S15, the control unit 11 (the storage processing unit 113) stores the writer information acquired in the step S14 in the storage unit 12 in association with the medical record information newly described in the electronic medical record. To do. Specifically, the control unit 11 stores the description person information and the medical record information in the storage unit 12 as the XML information D2. Then, the control unit 11 shifts the process to step S16.

<Step S16>
In step S16, the control unit 11 (the update processing unit 115) determines whether or not an update operation for updating the medical record information described in the electronic medical record has been performed. Then, when it is determined that the update operation has been performed (S16: Yes), the control unit 11 shifts the process to step S17, and determines that the update operation has not been performed (S16: No). ), The process shifts to step S19. The update operation is, for example, the double-click operation with a mouse.

<Step S17>
In step S17, the control unit 11 (the acquisition processing unit 112) acquires the writer information (that is, the writer identification information and the description date / time information) corresponding to the updated medical record information. Specifically, the control unit 11 acquires the user ID and user name of the logged-in user as the description person identification information, and acquires the current time as the description date and time information.

<Step S18>
In step S18, the control unit 11 (the storage processing unit 113) stores the writer information acquired in the step S17 in the storage unit 12 in association with the updated medical record information. Specifically, the control unit 11 stores the description person information and the medical record information in the storage unit 12 as the XML information D2. Then, the control unit 11 shifts the process to step S19.

<Step S19>
In step S19, the control unit 11 (display control unit 114) determines whether or not a display mode switching operation requesting the switching of the display mode has been performed. Then, when it is determined that the display mode switching operation has been performed (S19: Yes), the control unit 11 shifts the process to step S20 and determines that the display mode switching operation has not been performed. (S19: No), the process shifts to step S21. The display mode switching operation is, for example, a left-click operation of the mouse in the header area.

<Step S20>
In step S20, the control unit 11 (display control unit 114) switches the display mode. For example, when the current display mode is the first display mode, the control unit 11 switches to the second display mode. As a result, the writer information corresponding to the medical record information is displayed on the medical record screen P2. When the current display mode is the second display mode, the control unit 11 switches to the first display mode. As a result, the writer information corresponding to the medical record information is hidden on the medical record screen P2. Then, the control unit 11 shifts the process to step S21.

<Step S21>
In step S21, the control unit 11 (print control unit 116) determines whether or not a print operation requesting printing of the medical record information has been performed. Then, when it is determined that the printing operation has been performed (S21: Yes), the control unit 11 shifts the process to step S22, and when it is determined that the printing operation has not been performed (S21: No). ), The process shifts to step S23. The printing operation is, for example, an operation of a print button.

<Step S22>
In step S22, the control unit 11 (print control unit 116) causes the printer 30 to print the medical record information. Specifically, the control unit 11 generates print data including the medical record information and transmits the print data to the printer 30, and causes the printer 30 to print the medical record information. Here, when the second print mode is selected by the user, the control unit 11 causes the printer 30 to print the writer information together with the medical record information. On the other hand, when the first print mode is selected by the user, the control unit 11 causes the printer 30 to print only the medical record information. Then, the control unit 11 shifts the process to step S23.

<Step S23>
In step S23, the control unit 11 determines whether or not a save operation requesting the save of the chart information has been performed. Then, when it is determined that the save operation has been performed (S23: Yes), the control unit 11 shifts the process to step S24, and determines that the save operation has not been performed (S23: No). ), The process is shifted to step S25. The save operation is, for example, an operation of a save button.

<Step S24>
In step S24, the control unit 11 stores the medical record information in the medical record database D3. Specifically, the control unit 11 registers the medical record information included in the XML information D2 and the writer information associated with the medical record information in the medical record database D3. Then, the control unit 11 shifts the process to step S25.

<Step S25>
In step S25, the control unit 11 determines whether or not a user has performed a logout operation (for example, an operation of a logout button). Then, when it is determined that the logout operation has been performed (S25: Yes), the control unit 11 returns the process to step S11 and determines that the logout operation has not been performed (S25: No). ), The process returns to step S13.

As described above, in the electronic medical record device 10, the electronic medical record processing is executed by the control unit 11, and the description person information is acquired every time the medical record information is described in the electronic medical record. , The writer information is stored in the storage unit 12 in association with the medical record information. Therefore, it becomes possible to know when and who described the individual medical record information described in the electronic medical record.

Further, in the electronic medical record device 10, the description person information is displayed on the medical record screen P2 displayed when the medical record information is described in the electronic medical record. Therefore, for example, even if a doctor notices that the electronic medical record contains incorrect medical record information by another user while the medical record is being described in the electronic medical record, who describes the medical record information. You can tell immediately if you did.

Further, in the electronic medical record device 10, the first display mode in which the writer information is not displayed and the second display mode in which the writer information is displayed can be arbitrarily switched. Therefore, for example, the first display mode is basically used, and the display mode is arbitrarily switched depending on the situation, such as temporarily switching to the second display mode only at the confirmation work before performing the save operation. Can be switched.

Further, in the electronic medical record device 10, when the medical record information is described by a substitute, the identification information of the substitute and the identification information of the target doctor are acquired and stored in association with the medical record information. Therefore, even when the medical record information is described by the agent, it becomes possible to know who is the doctor who made the agent describe the medical record information.

In the present embodiment, the server client system is configured by the electronic medical record device 10 and the client terminal 20, and the electronic medical record program is executed in the electronic medical record device 10, but the present invention is not limited thereto. In another embodiment, the electronic medical record program may be executed on any of the client terminals 20. In this case, the electronic medical record device 10 may function as a mere data server. In still another embodiment, the electronic medical record system 1 may be composed only of a stand-alone information processing device that executes the electronic medical record program.

Further, in the present embodiment, the medical record information and the writer information once stored as the XML information D2 are finally stored in the medical record database D3, but the present invention is not limited thereto. In another embodiment, for example, the medical record information and the writer information may be stored for a long period of time as the XML information D2. Alternatively, the control unit 11 may save the medical record information and the writer information corresponding to the medical record information in the medical record database D3 at any time each time the medical record information is described in the electronic medical record.

Further, in the present embodiment, one target doctor is registered in advance for one substitute, but the present invention is not limited to this. In other embodiments, for example, a plurality of target doctors may be pre-registered for one agent. In this case, the control unit 11 may allow the agent to select one target doctor from the plurality of target doctors on the login screen displayed when the agent logs in.

Further, in the present embodiment, the writer information regarding the electronic medical record to be edited at present is displayed in the display area A2 of the medical record screen P2, but the present invention is not limited to this. In another embodiment, the control unit 11 may display the writer information regarding the electronic medical record created in the past, for example, in the display area A1 of the medical record screen P2.

Further, in the present embodiment, in the second display mode, the medical record information and the writer information corresponding to the medical record information are displayed adjacent to each other, but the present invention is not limited to this. In another embodiment, for example, the control unit 11 may pop up and display the writer information corresponding to the medical record information in response to the pointer being moved onto the medical record information.

Further, in the present embodiment, in the second display mode, the plurality of the writer information is displayed in the same display mode (for example, all in gray), but the present invention is not limited thereto. In another embodiment, the control unit 11 may display the writer information in a different display mode (for example, different colors) for each writer, for example. In still another embodiment, the control unit 11 corresponds to the display mode of the writer information corresponding to the medical record information described by the currently logged-in user and the medical record information described by another user. The display mode of the writer information may be set to a different display mode. For example, the control unit 11 may set the latter display mode to a more conspicuous display mode than the former display mode.

Further, in the present embodiment, in the second display mode, the writer information corresponding to all the medical record information displayed in the display area A2 is displayed, but the present invention is not limited to this. In another embodiment, the control unit 11 may display only the writer information corresponding to a part of the medical record information displayed in the display area A2. For example, the control unit 11 displays only the writer information corresponding to the medical record information described by a user other than the currently logged-in user among the medical record information displayed in the display area A2. May be good.

1: Electronic medical record system 10: Electronic medical record device 11: Control unit 12: Storage unit 13: Display unit 14: Operation unit 15: Communication IF
16: Drive device 20: Client terminal 21: Control unit 22: Storage unit 23: Display unit 24: Operation unit 25: Communication IF
26: Drive device 30: Printer 40: Network B1 to B21: Medical record information W1 to W21: Person information

Claims (7)

A description processing unit that describes medical record information in an electronic medical record in response to an operation by the first user or an operation by a second user who is given the same authority as the first user and substitutes for the operation of the first user.
A storage processing unit that stores the writer identification information indicating the writer of the medical record information described by the description processing unit in the storage unit in association with the medical record information.
A display control unit that displays the writer information associated with the medical record information on the display unit together with the medical record information.
With
When the person who writes the medical record information is the second user, the storage processing unit stores the identification information indicating the second user in the storage unit as the writer identification information.
When the person who writes the medical record information is the second user, the display control unit uses the identification information of the first user and the second user based on the person identification information associated with the medical record information. Display the identification information of
Electronic medical record system. When the person who writes the medical record information is the second user, the storage processing unit provides identification information indicating the second user and identification information indicating the first user to be represented by the second user. Stored in the storage unit as the writer identification information,
The electronic medical record system according to claim 1. The display control unit displays a character indicating that the person who describes the medical record information is the substitute operator together with the identification information of the second user.
The electronic medical record system according to claim 1 or 2. The display control unit can switch between displaying and hiding the writer identification information according to a user operation.
The electronic medical record system according to any one of claims 1 to 3. Each time new medical record information is added to the same electronic medical record by the description processing unit, the storage processing unit associates the description person identification information indicating the person who wrote the new medical record information with the medical record information. Memorize in the memory
When displaying the electronic medical record, the display control unit displays the writer identification information associated with the medical record information together with each of the medical record information described in the electronic medical record.
The electronic medical record system according to any one of claims 1 to 4. When the first user and the second user are displayed side by side, the display control unit gives priority to the first user for display.
The electronic medical record system according to any one of claims 1 to 5. A description processing step for describing medical record information in an electronic medical record according to an operation by the first user or an operation by a second user who is granted the same authority as the first user and acts on behalf of the operation of the first user.
A storage processing step of storing the writer identification information indicating the writer of the medical record information described by the description processing step in the storage unit in association with the medical record information.
A display step for displaying the writer information associated with the medical record information on the display unit together with the medical record information.
Is an electronic medical record program that allows the processor to execute
In the storage processing step, when the writer of the medical record information is the second user, the identification information indicating the second user is stored in the storage unit as the writer identification information.
In the display step, when the writer of the medical record information is the second user, the identification information of the first user and the identification information of the second user are based on the writer identification information associated with the medical record information. Display identification information,
Electronic medical record program.

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