JP3416595B2 - Medical information recording system and medical information recording method - Google Patents

Description

Detailed Description of the Invention

[0001]

BACKGROUND OF THE INVENTION 1. Field of the Invention The present invention relates to a medical care information recording system for electronically recording medical care information together with recording date and time, and a medical care information recording method.

[0002]

2. Description of the Related Art A computer system (medical information recording system) for digitizing medical information and recording it in a file is known. Here, the medical information includes, for example, subjective information (medical history, etc.) spoken by the patient, objective information (findings, etc.) examined by the doctor, judgment of the doctor (name of injury or disease, etc.), action of the doctor (treatment, Information such as medication). The purpose of using the medical care information recorded by the medical care information recording system is the same as in the case of paper medical records, and doctors can look at past prescriptions and medical history for patients and refer to this prescription, and see the test results. Understand the medical condition and verify the therapeutic effect.

[0003]

The purpose of using the medical information recorded in the medical information recording system is the same as in the case of a paper medical record, and since it has a function as a history of the medical condition and treatment of the patient, it is recorded once. After that, it is necessary to prevent it from being overwritten. In addition, when it is rewritten, it is desired to record the fact as a record. It is an object of the present invention to, when the medical information is rewritten, record the fact so that the medical information can be used for a later audit.

[0004]

A medical information recording system according to claim 1 is a system for electronically recording medical information together with a recording date and time, and a final recording date and time storing means for storing the last recording date and time, and a medical treatment. When recording information, the record date and time of the medical care information is compared with the last record date and time of the last record date and time storage means, and if the last record date and time is new, a log storage means for storing the fact and the current input person as a log; When the information is recorded, the recording date and time thereof is newer than the final recording date and time of the final recording date and time storage means, and the final recording date and time is updated with the recording date and time of the recorded medical care information, and It is characterized by having. According to a second aspect of the medical information recording system of the present invention, the date and time acquired from the system clock is used as the medical information recording date and time. The medical care information recording system according to claim 3 is a system for recording medical care information together with recording date and time, and recording the medical record information when recording the medical record information, and a last record date and time storing means for storing the last record date and time. The date and time and the last recorded date and time of the last recorded date and time storage means are compared, and when the last recorded date and time is new, a log storage means for storing the fact and the current input person as a log, and the recorded date and time when medical information is recorded. And a last recording date and time updating means for updating the last recording date and time with the date and time acquired from the system clock on condition that the last recording date and time is newer than the last recording date and time of the last recording date and time storage means. The medical care information recording system according to claim 4 is a system for recording the medical care information in electronic form together with the recording date and time acquired from the system clock, and a clock changing means for changing the system clock, and when the system clock is changed. And a log saving unit for saving the date and time before the change and the date and time after the change as a log together with the current input person. The medical care information recording system of claim 5 is the system of claim 4
In the above, the log information storage means further stores the recording date and time of the medical information recorded by changing the system clock as a log. The medical information recording method according to claim 6 is a method for recording medical information together with a recording date and time, and recording the medical information at the time of recording the medical information and the final recording date and time stored in a predetermined storage area. If the last recorded date and time are compared, the fact and the current input person are saved as a log, and when the medical information is recorded, the recorded date and time is newer than the last recorded date and time stored in the predetermined storage area. Under the condition, the last recording date and time is updated with the recording date and time of the recorded medical care information. The medical information recording method according to claim 7 is a method of electronically recording medical information together with the recording date and time acquired from the system clock, and when the system clock is changed, the date and time before and after the change The feature is that it is saved as a log together with the input person.

[0005]

DESCRIPTION OF THE PREFERRED EMBODIMENTS FIG. 1 shows a configuration example of a medical care information recording system according to an embodiment. The illustrated recording system has a control device 20, a keyboard 11, a mouse (or other known pointing device) 12, a display 13, and a storage device 30. The control device 20 is composed of a program ROM, a work RAM, an MPU, a video RAM and the like. Functionally, a system control unit 21 having a control function of the entire apparatus, a display control unit 24 having a display control function of the display 13, and a file recording / reproducing unit 2 having a read / write function of each file of the storage device 30.
3. Has a system clock 26. The storage device 30 is configured as a device including a recording medium such as a hard disk. In the storage device 30, the patient information file 31,
A medical information file 32, a user information file 33, a log file 34, and a last recorded date file 35 are provided. Of course, the storage device 30 has files other than the above, but since they are not related to the gist of the present invention,
Illustration is omitted.

FIG. 2A shows the format of the patient information file 31. As shown, the patient information file 31
For each patient, information for identifying the patient such as an identification number for identifying the patient, a patient name, a kana name, a date of birth, and a sex is recorded.

FIG. 2B shows the format of the medical care information file 32. As shown, the medical care information file 32
For each medical treatment, the identification number for identifying the medical treatment, the medical treatment date and time, the input person, the recording date and time, the medical treatment information (the medical history, findings,
Substantial medical information such as injury / disease name / treatment / medicine) is recorded.

FIG. 3A shows the format of the user information file 33. As shown in the figure, the user information file 33 includes, for each user, an identification number for identifying the user,
User name, job type (doctor / nurse / clerk, etc.), input authority (information indicating presence / absence of input authority for each type of input information),
Administrator rights (whether to change the system clock), audit rights (whether to access log information), etc. are recorded.

FIG. 3B shows the format of the log file 34. As shown in the figure, in the log file 34, for each log, an identification number for identifying the log, a recorder name, a recording date and time, and a log type (in the case of reversal of the recording date and the last recording date /
The type of the system clock change) and the log contents are recorded.

FIG. 3C shows the format of the last recorded date file 35. As shown in the figure, in the last recorded date file 35, the recording date and time (final recording date and time) of the last recorded medical care information and the information indicating the person who recorded the medical information are recorded.
The last recorded date and time is the recorded date and time of the last medical information,
As this data, the recording date and time of the last medical information may be transcribed, or the date and time of the system clock when the last medical information is recorded as in the configuration of claim 3 may be recorded.
When the date and time of the medical information is recorded using the date and time of the system clock when the medical information is recorded as the date and time of the medical information, the final recording date and time recorded by the former and the final recording date and time by the latter are recorded. The recording date and time will be the same. However, when the date and time input by the recorder is used as the recording date and time of the medical information, the final recording date and time recorded by the former and the final recording date and time recorded by the latter are different.

A procedure for saving the change of the system clock as a log will be described with reference to the procedure of the time setting process in FIG.
When the time setting process is activated (S01), whether or not the current input person has the authority to change the system clock is checked by referring to the administrator authority information of the user information file (S03). In addition, who is the current input person,
It is assumed that the system knows it by entering the password when starting the system.

When it is determined in the check in step S03 that there is no authority to change the system clock (S03
No), an error message indicating that there is no authority is displayed on the display 13 (S15), and the time setting process ends.

When it is determined in the check in step S03 that the user has the authority to change the system clock (YES in S03), the current date and time is acquired from the system clock (S0
5), the time setting screen as illustrated in FIG. 4 is displayed (S07). As the date and time initially displayed, the data acquired in step S05 is adopted.

When the "OK" button is pressed on the time setting screen (S09), it is checked whether or not there is a change on the time setting screen, and if there is a change (YES in S11), it is acquired in step S05. The current date and time and the changed date and time are recorded in the log file together with the recorder (current input person) (S13).

When the recording date and time is older than the last recording date and time,
A procedure for saving the fact as a log will be described with reference to the process at the time of recording medical information in FIG. When the medical care information is recorded (YES in S21), the recording date and time of the medical care information is compared with the final recording date and time stored in the final recording date file, and if the current recording date and time is past ( YES in S23), the recording date and time of this time and the record person (current input person)
Is recorded in the log file together with the final recording date and time (S25). If the system acquires the recording date and time from the system clock, the current recording date and time is the date and time of the system clock when the medical care information was recorded. Further, in the case of a system in which the input person appropriately sets the recording date and time, it is the date and time set by the input person.

If the final recording date and time stored in the final recording date file is earlier than the check result in step S23 (NO in S23), the data of the final recording date file is the current recording date and time and the recording person ( It is updated with the current input person (S27).

A procedure for changing the system clock and checking for the presence or absence of medical care information recorded at a date and time earlier than the last recording date and time will be described with reference to the process at the time of inspection in FIG. When the audit process is activated (S31), it is checked whether the current input person has the audit authority by referring to the audit authority information of the user information file (S33). It should be noted that it is assumed that the current input person is known to the system by entering a password when starting the system.

If it is determined in the check in step S33 that the user does not have the audit authority (NO in S33), an error message indicating that the user does not have the authority is displayed on the display 13 (S37), and the audit processing is terminated.

When it is determined in the check in step S33 that the user has the audit authority (YES in S33), the log file is reproduced (S35), and first, in steps S41 to S41.
The processing of 45 / S47 is looped for the number of times of medical treatment. That is, the log information for one time is reproduced from the log file (S
41), the type is checked by referring to the log type information (S43).

In the above check, if the recording date is reversed, that is, if the log is recorded because the recording date and time of the medical information is past the final recording date and time, the log content is read and the recording date is recorded. Data to be displayed in the reverse tab is created (S45). On the other hand, in the case of a clock change, that is, in the case of a log recorded because the system clock has been changed, the log contents are read and data to be displayed in the clock change tab is created (S47). ). Note that logs other than these are not displayed in this audit process, so the logs are ignored.

In this way, when the loop for the number of times of medical treatment is completed, the inspection screens illustrated in FIGS. 5 and 6 are displayed. Figure 5
Shows the display of log contents when the recording date reversal tab is selected, and FIG. 6 shows the display of log contents when the clock change tab is selected. Note that, as shown in FIGS. 5 and 6, the displayed log contents may be switched by a tab, but a screen configuration for collectively displaying them may be adopted.

[0022]

According to the inventions of claims 1 to 3, when the record date and time of the medical information is past the last record date and time of the system, the fact and the recorder are saved as a log. It is possible to know the fact in the audit of, and to know whether or not the medical care information is corrected. Claims 4, 5,
According to the seventh aspect, when the system clock is changed, the date and time before and after the change and the recording person are saved as a log, so that the fact can be known in a later audit, which leads to correction of medical information. You can know if there is a possibility that the system clock has changed.

[Brief description of drawings]

FIG. 1 is a block diagram showing the configuration of a medical information recording system according to an embodiment.

FIG. 2A is an explanatory diagram showing a file format of a patient information file and FIG.

FIG. 3A is an explanatory diagram showing a file format of a user information file, FIG. 3B is a log file, and FIG.

FIG. 4 is an explanatory diagram illustrating a time setting screen.

FIG. 5 is an explanatory diagram exemplifying a state in which a recording date reversal tab screen is displayed on the inspection screen.

FIG. 6 is an explanatory diagram illustrating an example in which a screen of a time change tab is displayed on the audit screen.

FIG. 7 is a flowchart showing a procedure of time setting processing.

FIG. 8 is a flowchart showing a procedure for recording a log after recording medical information.

FIG. 9 is a flowchart showing the procedure of an audit process.

[Explanation of symbols]

26 system clock 30 storage devices

─────────────────────────────────────────────────── ─── Continuation of the front page (56) References JP-A-4-333973 (JP, A) JP-A-9-237304 (JP, A) JP-A-7-152937 (JP, A) (58) Field (Int.Cl. ⁷ , DB name) G06F 17/60 G06F 19/00 JISST file (JOIS)

Claims (7)

(57) [Claims] 1. A medical information recording system for electronically recording medical information together with recording date and time, wherein a final recording date and time storing means for storing the last recording date and time, and a recording date and time of the medical information when recording the medical information. The last recording date and time of the last recording date and time storage means is compared, and when the last recording date and time is new, a log storage means for storing the fact and the current input person as a log, and the recording date and time when the medical information is recorded, A medical information recording system comprising: a final recording date and time updating unit that updates the final recording date and time with the recording date and time of the recorded medical information, provided that it is newer than the final recording date and time of the final recording date and time storage unit. . 2. The medical information recording system according to claim 1, wherein the date and time acquired from the system clock is used as the recording date and time of the medical information. 3. A medical care information recording system for electronically recording medical care information together with recording date and time, wherein a last record date and time storing means for storing the last record date and time, and a recording date and time of the medical care information when recording the medical care information. The last recording date and time of the last recording date and time storage means is compared, and when the last recording date and time is new, a log storage means for storing the fact and the current input person as a log, and the recording date and time when the medical information is recorded, A medical information recording system, comprising: a final recording date and time updating unit that updates the final recording date and time with the date and time acquired from the system clock on condition that the final recording date and time is newer than the final recording date and time. 4. A medical information recording system for electronically recording medical information together with a recording date and time acquired from a system clock, the clock changing means for changing the system clock, and before the change when the system clock is changed. A medical information recording system, comprising: a log saving unit that saves the date and time of and the changed date and time as a log together with the current input person. 5. The medical information record according to claim 4, wherein the log storage unit further stores the recording date and time of the medical information recorded by changing the system clock as a log. system. 6. A medical information recording method for electronically recording medical information together with recording date and time, wherein when recording medical information, comparing the recording date and time of the medical information with the last recording date and time stored in a predetermined storage area. If the last recorded date and time is new, the fact and the current input person are saved as a log, and when medical information is recorded, the recorded date and time is newer than the last recorded date and time stored in the predetermined storage area. A medical information recording method, characterized in that the final recording date and time is updated with the recording date and time of the recorded medical information as a condition. 7. A medical information recording method for electronically recording medical information together with a recording date and time acquired from a system clock, wherein when the system clock is changed, the date before the change and the date after the change are currently input by the user. A medical information recording method characterized in that it is saved as a log together with.