JP3433142B2 - Electronic medical record device - Google Patents

Description

Detailed Description of the Invention

[0001]

BACKGROUND OF THE INVENTION 1. Field of the Invention The present invention relates to an electronic medical chart apparatus, and more particularly, to an electronic medical chart apparatus which imposes certain restrictions on changes of recorded medical care information.

[0002]

2. Description of the Related Art There has been provided a so-called electronic medical chart apparatus in which medical information is digitized and recorded in a recording medium such as a hard disk and displayed on a display or printed out as needed. In the electronic medical record device,
Medical information is recorded by a doctor or the like at the time of medical examination and medical treatment, as in the case of paper medical records. It is also approved by a person who has the authority such as a doctor. The purpose of using the recorded medical information 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,
The test results are used to understand the medical condition and verify the therapeutic effect.

[0003]

The purpose of using an electronic medical record is the same as that of a paper medical record, and since it has a function as a medical condition of a patient and a history of treatment, it is simple after approval by an authorized person such as a doctor. It is necessary to prevent rewriting indiscriminately unless there is a mistake in writing. It is an object of the present invention to impose certain restrictions on the change of the recorded contents of an electronic medical record so that it cannot be rewritten unless there is a legitimate reason such as a simple entry error.

[0004]

In each of the following configurations, it is premised that the medical information is recorded or rewritten with respect to the record of a certain medical day of a certain patient. In other words,
It is assumed that the medical care information can be selected for each patient and for each medical care day. The electronic medical chart apparatus according to claim 1 includes a changeable date calculating means for calculating a date which is a predetermined number of days before the system date as a changeable date of medical information, and a changeable date storing means for updating and storing the calculated changeable date. Medical information storage means for storing medical information, selection means for selecting a medical care date for medical information input, input mode command means for setting an input mode of medical information, and medical care for medical information input When the day is selected and the medical information input mode is instructed, the selected medical day is compared with the future of the changeable date stored in the changeable date storage means, and the changeable date is later. In the case of, the setting of the medical care information input mode is prohibited, and if it is not a later date, the medical care information input management means is provided, and the changeable date storage means is the changeable date previously stored. Can be changed The previous changeable date is updated with the calculated changeable date only when the changeable date calculated by the calculation means is compared later and the calculated changeable date is a later date. A characteristic electronic medical record device. That is, when the medical treatment date selected for rewriting the already recorded medical care information is a date before the changeable date, the device prohibits rewriting. If the medical treatment date selected as the medical information input target and the changeable date are the same, whether to permit or prohibit the change is a matter of choice in device design. In other words, it also includes a configuration in which the medical care information input management means is “allow the setting of the medical care information input mode if the changeable date is a future date and prohibit it if it is not a future date”. If the system date is returned to a date earlier than the actual date, the calculated changeable date will be earlier than the previously stored changeable date, so the calculated changeable date will be ignored. To be done.
That is, the previous changeable date is not updated with the calculated changeable date. In this case, the availability of the medical care information input mode (or medical care information input) by the medical care information input management means is determined based on the previous changeable date that has not been updated.
Therefore, by returning the system date, it is not possible to set the medical care date of the medical care information input target to a date after the changeable date. In the electronic medical record apparatus according to claim 2, the medical care information input management means according to claim 1 prohibits or permits the input of the medical care information instead of prohibiting or permitting the setting of the medical care information input mode. Is characterized by. That is, claim 1
In the above, rewriting is prevented by prohibiting the setting of the medical care information input mode (prohibiting transition to the medical care information input screen and opening of the medical care information input window). Prohibition prevents rewriting. This claim 2 is, for example, the case of an apparatus configured to input medical care information on a medical care information screen or the like without an input-only screen called a medical care information input screen or an input-only window called a medical care information input window. The electronic medical chart apparatus according to claim 3 has a means for storing the approver of the medical information in association with the medical information according to any one of the first and second aspects, and the medical information input management means is the medical information input management means. The permission condition is that the person who selects the medical treatment date of the information input target and the approver of the medical treatment information of the input target are the same. According to a fourth aspect of the present invention, in the electronic medical chart apparatus according to any one of the first to third aspects, the changeable date calculating means calculates when the system is started. In addition, when the system is always in the operating state, for example, it is possible to perform the calculation at a predetermined time.

[0005]

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS FIG. 1 shows an example of the configuration of an electronic medical chart device according to an embodiment. As shown, the electronic medical record device
It 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, a file recording / reproducing unit 23 having a read / write function of each file of the storage device,
It has a system clock 26. The storage device 30 is, for example,
It is configured as an apparatus including a recording medium such as a hard disk. A medical information file 31 is provided in the storage device 30. Of course, the storage device 30 has files other than the medical care information file 31, but they are not shown because they are not related to the gist of the present invention.

The medical care information file 31 has the tables shown in FIGS. 6 and 7. The medical care information changeable date table stores the medical care information changeable date (also simply referred to as “changeable date”). That is, when the electronic medical chart device is activated, the system control unit 21 reads the system date from the system clock 26, and obtains a date that is a predetermined number of days (for example, 30 days) past the read system date as the changeable date.

Next, the changeable date (new) obtained as described above is compared with the changeable date (previous) stored in the medical information changeable date table, and the changeable date obtained this time is changed. Only when the date (new) is later than the changeable date (previous) stored in the medical information changeable date table, the changeable date (new) obtained this time is the previous changeable date. To update. If the changeable date (new) obtained this time is not later than the changeable date stored before, the update is not performed, and the previous changeable date continues to be stored. The above processing is shown in the flowchart of FIG. The medical information changeable date table may be updated, that is, the changeable date may be calculated when the electronic medical chart device is started. However, for example, in an environment where the electronic medical chart device is not turned off, the calculation and update are performed at a predetermined time every day. May be performed.

In the patient table, the name and code of each patient are stored in association with the patient ID. In the user table, each user who uses the electronic medical chart device (doctor etc.)
The name, job type, and presence / absence of approval right are stored in association with the user ID. The approval right is an authority to approve the description content of the medical record, and for each medical record of each medical treatment day of each patient, the user ID of the user who has approved the medical record is recorded in association with the medical record ( See the medical information table). Further, the approval date and time is recorded as the recording date and time of the medical record (see the medical information table). Later, if you want to rewrite the medical record of a certain medical treatment day of a certain patient,
The approver ID of the medical record is checked with the user ID of the user who rewrites, and rewriting is permitted only when both match. That is, rewriting is permitted only to the approved user.

In the medical care information table, the patient ID, the approver ID, the examination date and time, and the recording date and time are stored in association with the medical treatment information ID. Further, in the medical care content table, the medical care information ID, the deletion flag, the recording date and time, and the medical care content details (substantial contents of medical care information such as chief complaint, current medical history, findings, medical history, and family history) are included in the medical care content ID. It is associated and stored.

When a certain medical examination date (medical treatment date) of the patient displayed on the medical treatment information screen of FIG. 2 is selected with the pointing device (in FIG. 2, the medical record on April 3, 1999 is selected). (Shown), the medical care information ID associated with both the patient ID of the patient in question and the selected consultation date (in this case, April 3, 1999) in the medical care information table (in this case, "medical care" Information ID = 3 "; refer to medical information table) is specified.

After specifying the medical care information ID, when the medical care information input button in the medical care information screen of FIG. 2 is pressed with the pointing device, the information of the medical care content table is read according to the specified medical care information ID, It is displayed on the medical care information input screen (FIG. 3) shown in FIG. However, the following restrictions are imposed on the transition to the medical information input screen (FIG. 3), that is, the setting of the medical information input mode.

First, the approver ID (in this case, “approver ID = 2”; refer to the medical information table) associated with the specified medical information ID (in this case “medical information ID = 3”) , It is checked whether it is the same as the user ID of the current user. The user ID of the current user is
It is assumed that the password, fingerprint collation, voice print collation, etc. have been confirmed. As a result of the above check, if the current user ID and the approver ID are not the same (step S5 in FIG. 5).
5: NO), an error message is displayed indicating that rewriting of medical information is not permitted except for the approver (step S6).
1). That is, the transition to the medical care information input screen (FIG. 3) (= setting of the medical care information input mode) is not performed.

ID of the current user in step S55
And the approver ID are the same, next, from the medical information changeable date table and the recording date and time associated with the specified medical information ID (in this case, “medical information ID = 3”) The readability of the changeable date is checked. As a result, if the date of the recording date and time is not after the changeable date (step S57: NO), an error message "Rewriting is not permitted because the changeable period has elapsed" is displayed (step S63). That is, also in this case, the transition to the medical care information input screen (FIG. 3) (= setting of the medical care information input mode) is not performed.

If the date of the recording date and time is a date after the changeable date in step S57, the transition to the medical care information input screen of FIG. 3 is permitted (step S59), and the medical record of the selected medical care date is displayed. Rewriting is possible. A deletion flag is set for the medical care information deleted by rewriting on the medical care information input screen (see the medical care content table). That is, the deleted medical care information is stored as data. The above processing is shown in the flowchart of FIG.

The medical care information screen of FIG. 2 referred to in the above description is a screen for displaying the recorded medical care information for each medical care day. The medical care information input screen of FIG. 3 is a screen for selecting desired medical care information from the medical care information input fields displayed by selecting it in the medical care information selection field and inputting its contents. The medical care information input and confirmed in this input field is recorded in the medical care content table described above.

[0016]

According to each claim of the present invention, when the medical treatment date selected for rewriting the recorded medical information is a date before the changeable date, the rewriting is prohibited, and therefore the recorded information is not recorded. The rewriting of medical information can be performed only within a certain period (for example, 30 days). As this period, a period sufficient for correcting a simple description error and for preventing rewriting of a medical record without a valid reason is selected. The changeable date storage means compares the changeable date previously stored with the newly calculated changeable date before and after, and calculates only when the calculated changeable date is a later date. Update the previous changeable date with the changeable date. Therefore, when the system date is returned to a date before the actual date, the previous changeable date is not updated. Therefore, an attempt to return the system date to the medical treatment date input target medical treatment date after the changeable date does not work. In the electronic medical chart apparatus according to claim 3, rewriting is permitted only to a person who has the authority to approve the medical chart.

[Brief description of drawings]

FIG. 1 is a block diagram showing a configuration of an electronic medical chart device according to an embodiment.

FIG. 2 is an explanatory diagram illustrating a medical information screen.

FIG. 3 is an explanatory diagram illustrating a medical information input screen.

FIG. 4 is a flowchart showing a procedure for updating a changeable date.

FIG. 5 is a flowchart showing a procedure for determining whether to allow transition to a medical information input screen.

FIG. 6 is an explanatory diagram illustrating a medical information changeable date table, a patient table, and a user table.

FIG. 7 is an explanatory diagram illustrating a medical care information table and a medical care content table.

[Explanation of symbols]

31 Medical information file

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Claims (4)

(57) [Claims] 1. A changeable date calculation means for calculating a predetermined number of days before the system date as a changeable date of medical information, a changeable date storage means for updating and storing the calculated changeable date, and medical information. The medical care information storage means to be stored, a selection means for selecting a medical care date of the medical care information input target, an input mode command means for setting the medical care information input mode, and a medical care date of the medical care information input target are selected. When the medical care information input mode is instructed, the selected medical care date and the changeable date stored in the changeable date storage means are compared before and after, and if the changeable date is later, medical treatment is performed. Medical information input management means for prohibiting the setting of the information input mode and permitting it if it is not a later date, wherein the changeable date storage means is the changeable date and the changeable date previously stored. Computing means Comparing the later calculated changeable dates and updating the previous changeable date with the calculated changeable date only when the calculated changeable date is a later date. Electronic medical record device. 2. The medical information input management means according to claim 1, wherein instead of prohibiting or permitting setting of the medical information input mode, the medical information input is prohibited or permitted. A characteristic electronic medical record device. 3. The medical information input management means according to claim 1, further comprising means for storing an approver of the medical information in association with the medical information. An electronic medical chart apparatus, characterized in that the person who has selected a medical treatment date and the person who approves the medical information to be input are the same as a permission condition. 4. The method according to any one of claims 1 to 3, The changeable date calculation means calculates when the system is started, An electronic medical record device characterized by the above.