JP4434536B2 - Electronic medical record system - Google Patents

Description

[0001]
BACKGROUND OF THE INVENTION
The present invention relates to an electronic medical record system that performs input / management of an electronic medical record that electronically records medical care information generated in a clinic and other medical institutions, and in particular, a burden when a doctor inputs medical information into the electronic medical record. The present invention relates to an electronic medical record system that can reduce the risk.
[0002]
[Prior art]
In general, in a medical institution such as a clinic where a hospital information system is well-equipped, reception registration of a visit patient is performed by an input operation using a reception terminal. In such a medical institution, a doctor calls a list of registered patients input from the reception terminal using a doctor terminal provided for each clinic, and further designates a corresponding patient from the list of registered patients. Then, the patient's medical chart (electronic medical chart) is called and information regarding the patient's electronic medical chart is input.
[0003]
Information input regarding this electronic medical record is performed by a doctor using a doctor's terminal to input information such as the main complaint, findings, etc., schema, and order contents according to the medical condition of the medical patient's electronic medical record. This is done by individually searching / selecting the definition contents and inputting them. If the patient is a revisited patient, the patient's past medical chart information may be called, copied as it is, and input to the current electronic medical chart.
[0004]
In addition, some electronic medical records display on a screen whether or not there is information on examination results and image diagnosis results related to a patient. In such a case, the doctor determines whether or not there is information on the examination result or the image diagnosis result from the display content displayed on the screen, and if there is the result, activates each screen and confirms the content. / Judgment is conducted at the discretion.
[0005]
In this way, a system that provides a medical practice for a patient of a doctor using an electronic medical record that electronically records medical information generated in a clinic and other medical institutions is referred to as an electronic medical record system.
[0006]
[Problems to be solved by the invention]
However, the conventional electronic medical chart system described above has various problems described below.
[0007]
(1) In the conventional electronic medical chart system, when a doctor selects a patient waiting for a medical examination using a doctor terminal, it is necessary to select the patient by starting another screen or automatically starting another screen. . Accordingly, since the screen is switched and the position of the viewpoint at the time of input is also moved, there is a problem that the input is troublesome and tired. In fact, in many cases, patients are selected in the order of acceptance or in the order of reservation, but the conventional electronic medical chart system is not set to display the screen in such an order. There is a problem that it takes time and effort when a doctor selects a patient for medical care.
[0008]
(2) The number of patients who come to a medical institution is overwhelmingly large when comparing first-visit patients and returning patients. For example, a physician or the like has a very large proportion of chronically ill patients, and moreover, in the case of chronically ill patients, it is difficult to heal, so there are many cases where the same medical practice as the previous time is repeated. However, in the conventional electronic medical record system, even in this case, the doctor refers to the previous main complaint, findings, schema diagram, order contents, etc. It was necessary to input information into the electronic medical record. Therefore, there is a problem that it takes time to input.
[0009]
(3) In addition, in the case of epidemic patients caused by seasons such as influenza and hay fever, the symptoms are the same for all patients, so the prescribed medications and treatment details may be exactly the same. Many. However, in the conventional electronic medical chart system, the doctor needs to input the same content for each patient, the findings, the schema, and the order content for each patient with the same medical treatment content. there were. Therefore, there is a problem that it takes time to input.
[0010]
(4) For example, a doctor in charge of surgery often uses a schema diagram for medical treatment. However, in the conventional electronic medical chart system, when creating the schema diagram, it is necessary to select the template of the schema diagram on another screen and edit the contents. Therefore, there is a problem that the doctor needs to start another screen each time and edit the content, which takes time and effort.
[0011]
(5) Also, there are many cases where prescriptions, treatments, and examination contents frequently performed for a plurality of patients are input. However, in the conventional electronic medical record system, when information about the patient is input, for example, in the case of prescription, whether or not the same prescription has been performed in the past for the patient, and if there is no prescription history, Furthermore, a procedure for displaying a search screen for prescription drugs, performing a narrow search for drugs, inputting usage, and confirming the contents was necessary. Therefore, there is a problem that the input action is complicated and time-consuming.
[0012]
(6) Regarding the reference of the inspection result and the image diagnosis result, the current one and the previous one are often compared. However, in the conventional electronic medical record system, when a doctor refers to the previous examination result and image diagnosis result regarding the medical patient, it is necessary to search for this. There was a problem of forgetting to refer to the contents of. There is also a problem that omission of registration in the electronic medical record system such as examination results and image diagnosis results cannot be found.
[0013]
(7) Further, in the conventional electronic medical chart system, when the doctor displays the electronic medical chart information on the screen of the doctor terminal, all the input contents may be developed and displayed on the screen for the convenience of the computer terminal. Because it is physically difficult, it was necessary to confirm the content again on a separate screen when finalizing all the medical treatment details of the patient. Therefore, there has been a problem that a registration error of electronic medical record information by a doctor may occur.
[0014]
Since doctors need to process these contents simultaneously with busy examination, there is a problem that the doctor cannot concentrate on the original medical practice.
[0015]
The present invention has been made in view of the above problems, and an object of the present invention is to input / manage an electronic medical record for electronically recording medical information generated in clinics and other medical institutions. It is an object of the present invention to provide an electronic medical record system that can reduce the burden of inputting medical information into a doctor's electronic medical record so that the doctor can concentrate on the original medical practice.
[0016]
[Means for Solving the Problems]
In order to solve the above-mentioned problem, the invention described in claim 1 is an electronic medical chart system that includes a database, a display unit, an input unit, and a control unit, and creates an electronic medical record that records medical treatment contents related to a patient's medical treatment. The database includes electronic medical record information including disease name information items and a plurality of medical information items. And a plurality of shortcut names that are individual components of the electronic medical record information are stored in association with each other, The control means includes the electronic chart information and the electronic information on the display unit. plural Shortcuts Name And the shortcut by the input means Name But Choice Based on the instruction, the shortcut is referred to the database. Name And a control unit that performs control to simultaneously display the medical treatment contents of the patient together with the electronic medical record information and present it as a new electronic medical record template.
[0028]
DETAILED DESCRIPTION OF THE INVENTION
DESCRIPTION OF EMBODIMENTS Hereinafter, an embodiment of an electronic medical record system according to the present invention will be described with reference to the drawings, taking an embodiment for each claim.
[0030]
As shown in FIG. 1, the electronic medical record system according to the present embodiment mainly includes a reception terminal 1 that performs reception registration and electronic medical record creation for a visiting patient, and a doctor that calls and inputs the electronic medical record of the patient. It is comprised from the terminal 2, the hub 3, and the electronic medical record server apparatus 4 which manages the electronic medical record of a registered patient.
[0031]
When the patient visits, first, the reception terminal 1 is used to register the patient and create an electronic medical record. At this time, a queue of reception information is created according to the reception time or the reservation time. The queue of reception registration information / electronic medical record information and reception information is stored in the electronic medical record server device 4 and managed as a database. In the reception registration information, time information such as reception (reservation) time and examination time is managed.
[0032]
When a doctor calls an electronic medical record related to a registered patient in order to select a patient to be treated from now on using the doctor terminal 2 installed in each clinic, the patient who is waiting for a diagnosis that operates in the doctor terminal 2 The automatic display function is configured to display an electronic medical record of a patient having the oldest reception (reservation) time waiting for a medical examination of the doctor in accordance with a queue of reception registration information relating to the registered patient, undiagnosed (no examination time input). Call to the screen of the doctor terminal 2.
[0033]
Note that the reception registration information queue has various operation variations in accordance with the operation method of the medical institution. For example, in a medical institution that manages patient examinations for each doctor, the reception registration information is assigned to each doctor. In addition, in the case of a medical institution that operates in order by a plurality of doctors for each department, reception registration information is assigned to each department.
[0034]
2 and 3 are flowcharts for explaining the process described above along the processing of the electronic medical chart system.
[0035]
As shown in FIG. 2, when a patient comes to the hospital, first, the reception terminal performs patient registration and electronic medical record creation (S01). At this time, a queue of reception information is created according to the reception time or the reservation time (S02). The queue of reception registration information / electronic medical record information and reception information is stored in the electronic medical record server device (S03).
[0036]
Next, as shown in FIG. 3, the doctor calls up an electronic medical record relating to a registered patient in order to select a patient to be treated from now on using a doctor terminal installed in each clinic (S04). Then, the automatic display function of the patient waiting for examination operating in the doctor terminal 2 refers to the queue of the reception registration information relating to the registered patient (S05), and whether or not the patient is not examined (the examination time is not entered). (S06), it is determined whether the doctor is waiting for a medical examination (S07), and further, it is determined whether the oldest reception (reservation) time is present (S08), The patient's electronic medical record corresponding to this is called and displayed on the screen of the doctor terminal (S09).
[0037]
It should be noted that the reception information is distributed according to the operation method of the medical institution, for example, in the medical institution managing the patient's examination for each doctor, and for each doctor, the registration information is assigned to each department in order by a plurality of doctors. In the case of an operating medical institution that conducts medical examinations, it can also be assigned to each department.
[0038]
In the above embodiment According to such an electronic medical record system, when a doctor selects a patient to be treated in the future, the patient's selection is automatically performed only by calling the registered patient's electronic medical record using the doctor terminal. Since the electronic medical record of the corresponding patient is displayed, it is possible to eliminate the annoyance and trouble felt by the input operation when the doctor selects the patient.
[0039]
next, In other embodiments The electronic medical record system will be described with reference to an example (for example, simplification of a medical practice input method).
[0040]
FIG. 1 is applied mutatis mutandis to show the overall configuration of the electronic medical chart system in the present embodiment. As shown in the figure, the electronic medical record system according to the present embodiment mainly includes a reception terminal 1 for performing registration and electronic medical record creation for a patient visited by a doctor, and a doctor who calls and inputs the electronic medical record of the patient. It is comprised from the terminal 2, the hub 3, and the electronic medical record server apparatus 4 which manages the electronic medical record of a registered patient.
[0041]
FIG. 4 shows a configuration example of a database related to simplification of an electronic medical record input method (medical practice input method) in the doctor terminal of the electronic medical record system according to the present embodiment. As shown in the figure, the medical treatment set master 10 includes a prescription set master 11, an injection set master 12, a treatment set master 13, an examination set master 14, an image set master 15, a rehab reset master 16, a meal set master 17, and a reminder master. The order information such as 18 is associated with the chief complaint / finding template master 20, the schema master 21, and the disease name master 22, and these contents are created for each doctor. Hereinafter, the individual components of the medical treatment set master 10 (prescription set master 11, injection set master 12, treatment set master 13, examination set master 14, image set master 15, rehabilitation reset master 16, meal set master 17 and reminder master 18) is referred to as a shortcut. In this embodiment, in addition to this shortcut, for example, a shortcut is set for the following classification and used.
(1) Seasonal epidemic names ... Specific examples: influenza, hay fever, etc.
(2) By syndrome: Specific examples: chest pain (heart), chest pain (lung), etc.
(3) Chronic disease name: Specific examples: hypertension, diabetes, chronic gastritis
(4) Frequent orders: Specific examples: insomnia, chest X-ray, liver function test, etc.
[0042]
Further, FIG. 5 shows a display screen on which the shortcut is displayed. As shown in the figure, so-called medical accounting delivery software (medical reminder) is installed in the doctor terminal 2 of the electronic medical record system, and the display contents (display screen) in this medical reminder are described below. It is the contents. As shown in the figure, the display screen in the medical reminder includes a display part 30 for the patient's name, gender, date of birth, etc., as well as an electronic medical chart display part 31 for showing the patient chart information, and a guidance fee for the patient. It includes a guidance fee execution information display portion 32 that shows information, and a shortcut display portion 33 that displays the shortcut, which is means for searching for medical information of the patient according to a predetermined condition. Further, the electronic medical record display part 31 includes a medical doctor display part 31a indicating the name of the medical doctor in charge regarding the patient of the electronic medical record, a finding display part 31b indicating the findings, a schema information display part 31c indicating the schema, and order information indicating the order contents. The display part 31d is configured. The doctor-in-charge display portion 31a further includes scroll buttons 310a to 310c for sequentially scrolling the electronic medical records to be displayed. Further, in the present embodiment, the shortcut display portion 33 displays the contents of the electronic medical record with the disease name 33a (corresponding to the disease name master 22 of FIG. 4 and the chronic disease name of (3) above), the season 33b ((1) above) ), A syndrome 33c (corresponding to the seasonal epidemic name of (2) above), a prescription 33d (corresponding to the prescription set master 11 of FIG. 4), an image 33e (image set master of FIG. 4). 15), examination 33f (corresponding to examination set master 14 in FIG. 4), medical system 33g, etc., and a plurality of shortcuts for searching information. These shortcuts are displayed in different colors for each category in order to improve visibility.
[0043]
Using the doctor terminal 2 in which the medical reminder is installed, the doctor first refers to the list of registered patients, selects a patient to be treated from this, and obtains the electronic medical record information of the patient from the electronic medical chart device 1 call. Then, on the patient's electronic medical record information display screen, the medical treatment contents corresponding to the corresponding conditions are displayed on the screen using the shortcut.
[0044]
FIG. 6 shows a screen display of the medical treatment contents corresponding to the corresponding condition by selecting / using chronic bronchitis of the disease name 33a (corresponding to the disease name master 22 of FIG. 4) as the shortcut. As shown in the figure, by selecting / using chronic bronchitis of the disease name 33a (corresponding to the disease name master 22 of FIG. 4) which is the shortcut, electronic medical record information regarding the chronic bronchitis of the patient is displayed. At this time, the findings display section 31b displays the findings regarding the patient's chronic bronchitis, the schema information display section 31c displays a schema diagram regarding the patient's chronic bronchitis, and the order information display section 31d displays The order contents regarding the chronic bronchitis of the patient are displayed.
[0045]
7 and 8 are flowcharts for explaining the process described above along the processing of the electronic medical chart system.
[0046]
As shown in FIG. 7, when a patient comes to the hospital, patient registration and electronic medical chart creation are first performed by the reception terminal (S10). These reception registration information and electronic medical record information are stored in the electronic medical record server device (S11). When a doctor performs a medical practice on a registered patient, the doctor's terminal is used to call the patient's electronic medical record from the electronic medical record server device (S12), and information regarding the medical practice is stored in the patient's electronic medical chart. Input (S13). The electronic medical record information (input information) is stored in the electronic medical record server device (S14).
[0047]
Thereafter, each time a medical practice is performed on the patient, the processes of S12 to S14 are repeated, and the electronic medical record information of the patient is updated as needed.
[0048]
When performing a medical practice on the patient, the doctor selects the patient from a list of registered patients as shown in FIG. 8 using a doctor terminal installed in each clinic (S15). ). And the electronic medical chart information regarding the said patient is called from an electronic medical chart server apparatus (S16). Then, the patient's electronic medical record is displayed on the display screen of the doctor terminal (S17). Here, when searching for past medical treatment contents related to the patient, the doctor selects a shortcut for displaying the contents under a desired condition from the shortcuts displayed together with the electronic medical record of the patient (S18). Then, medical information corresponding to the shortcut condition is searched in the electronic medical record server device (S19), and the corresponding medical information is displayed on the screen (S20).
[0049]
like this In the embodiment According to the electronic medical record system, electronic medical record information about the patient (personal information such as name, gender, date of birth, etc., main complaint findings information, schema information, order information, disease name information, etc.) and shortcut functions By using the shortcut, the doctor uses the shortcut to display the medical contents of the patient in the past (symptom contents, schema diagram, order contents, disease name contents, instruction fee calculation contents, etc.) for each desired condition. Can be automatically expanded on the same screen. In addition, by creating a new electronic medical record using such a template, it is possible to shorten the time related to the input of the doctor's electronic medical record.
[0050]
Note that, for example, the screen contents corresponding to the operation of each medical institution can be structured by hierarchizing the shortcuts.
[0051]
In addition, for example, by referring to past medical chart contents and searching for and registering frequent orders (and combinations thereof), it is possible to simplify the editing of shortcut contents. Also, by registering the contents being developed on the doctor screen as a shortcut, simple registration of the shortcut can be realized.
[0052]
In addition, by associating these shortcuts with, for example, a keyword of about two characters and linking this keyword content with handwritten character recognition means, it is possible to simplify input. In the present embodiment, the keyword can be input by handwriting using a character input means such as a liquid crystal pen tablet within the display area of the character recognition portion 34 shown in FIG.
[0053]
Further, by associating these shortcuts with a keyword of, for example, about two characters and linking this keyword content with the voice recognition means, it is possible to simplify input. Actually, a huge amount of dictionaries are required to create a speech dictionary, but it is practical because it can reduce the effort, time and number of vocabularies to be registered in the speech dictionary by using about 2 characters. Is.
[0054]
next, In other embodiments Such an electronic medical record system will be described with reference to examples (eg, automating the reference of examination results and image diagnosis results).
[0055]
FIG. 1 is applied mutatis mutandis to show the overall configuration of the electronic medical chart system in the present embodiment. As shown in the figure, the electronic medical record system according to the present embodiment mainly includes a reception terminal 1 for performing registration and electronic medical record creation for a patient visited by a doctor, and a doctor who calls and inputs the electronic medical record of the patient. It is comprised from the terminal 2, the hub 3, and the electronic medical record server apparatus 4 which manages the electronic medical record of a registered patient.
[0056]
Moreover, FIG. 4 is applied mutatis mutandis, and the example of 1 structure of the database regarding simplification of the electronic medical record input system (medical practice input system) in the said doctor terminal of the electronic medical record system in this embodiment is shown. As shown in the figure, the medical treatment set master 10 includes a prescription set master 11, an injection set master 12, a treatment set master 13, an examination set master 14, an image set master 15, a rehab reset master 16, a meal set master 17, and a reminder master. The order information such as 18 is associated with the chief complaint / finding template master 20, the schema master 21, and the disease name master 22, and these contents are created for each doctor. Hereinafter, the individual components of the medical treatment set master 10 (prescription set master 11, injection set master 12, treatment set master 13, examination set master 14, image set master 15, rehabilitation reset master 16, meal set master 17 and reminder master 18) is referred to as a shortcut. In this embodiment, in addition to this shortcut, for example, a shortcut is set for the following classification and used.
(5) Names of epidemics by season: Specific examples: influenza, hay fever, etc.
(6) By syndrome: Specific examples: chest pain (heart), chest pain (lung), etc.
(7) Chronic disease name: Specific examples: hypertension, diabetes, chronic gastritis
(8) Frequent orders: Specific examples: insomnia, chest X-ray, liver function test, etc.
[0057]
Furthermore, FIG. 6 is applied mutatis mutandis and the display screen in the said doctor terminal 2 of the electronic medical chart system in this embodiment is shown. As shown in the figure, so-called medical accounting delivery software (medical reminder) is installed in the doctor terminal 2 of the electronic medical record system, and the display contents (display screen) in this medical reminder are described below. It is the contents. As shown in the figure, the display screen in the medical reminder includes a display part 30 for the patient's name, gender, date of birth, etc., as well as an electronic medical chart display part 31 for showing the patient chart information, and a guidance fee for the patient. It includes a guidance fee execution information display portion 32 that shows information, and a shortcut display portion 33 that displays the shortcut, which is means for searching for medical information of the patient according to a predetermined condition. Further, the electronic medical record display part 31 includes a medical doctor display part 31a indicating the name of the medical doctor in charge regarding the patient of the electronic medical record, a finding display part 31b indicating the findings, a schema information display part 31c indicating the schema, and order information indicating the order contents. The display part 31d is configured. The doctor-in-charge display portion 31a further includes scroll buttons 310a to 310c for sequentially scrolling the electronic medical records to be displayed. Further, in the present embodiment, the shortcut display portion 33 displays the display contents of the electronic medical record with the disease name 33a (corresponding to the disease name master 22 of FIG. 4 and the chronic disease name of (3) above), the season 33b ((1) above) ), A syndrome 33c (corresponding to the seasonal epidemic name of (2) above), a prescription 33d (corresponding to the prescription set master 11 of FIG. 4), an image 33e (image set master of FIG. 4). 15), examination 33f (corresponding to examination set master 14 in FIG. 4), medical system 33g, and the like. These shortcuts are displayed in different colors for each category in order to improve visibility.
[0058]
When performing a medical practice on a patient, a doctor calls the patient's electronic medical chart information from the electronic medical chart apparatus 1 using the doctor terminal 2 in which the medical reminder is installed. At this time, the corresponding contents are displayed on the screen using the shortcut described above.
[0059]
Furthermore, in the electronic medical chart system according to the present embodiment, a button having a shortcut function for referring to the examination result and image diagnosis result of the patient is displayed on the display screen of the doctor terminal 2.
[0060]
The doctor selects / uses the test result button 35 and the image result button 36 shown in the lower right of the display screen shown in FIG. As described above, the examination result and the image diagnosis result of the patient can be automatically displayed on the screen. The test result 40 shown in FIG. 9 shows the test result related to the blood component of the patient, the personal information display portion 41 related to the patient such as name, gender, date of birth, and disease name, and the test result to be displayed. The inspection result classification designation portion 42 for performing the classification designation, the inspection result display portion 43 for displaying the graph as the inspection result, the inspection item display portion 44 for displaying the inspection items, and the like.
[0061]
Furthermore, for example, by managing three pieces of information of examination instruction date / time, sample collection date / time, and result registration date / time as examination order information, the processing related to display is changed according to the flowchart shown in FIG. 10 according to these dates. The automatic display of the inspection result can be realized.
[0062]
The flowchart shown in FIG. 10 will be described. As shown in the figure, the doctor uses the doctor terminal 2 to select a patient to be treated from a list of accepted patients (registered patients) (S01). At this time, the electronic medical record information of the patient is retrieved / referenced from the reception table stored in the database in the electronic medical record server device 4 (S02), and it is determined whether or not the patient is the first visit (S03). If the patient is a return patient, it is further determined whether or not there has been an instruction to have the patient undergo an examination (S04). If there is an instruction to have the patient undergo a test, it is further determined whether or not the test result is present (S05). When the patient has a test result, the test result of the patient is referred to in the test result table (S06) and automatically displayed (S07). In addition, when notifying that the patient is inspected or when there is no inspection result regarding the patient (unregistered), it is possible to display a warning indicating that fact.
[0063]
in this way, In this embodiment According to such an electronic medical record system, the doctor can automatically display the examination result and the image diagnosis result of the patient using the examination result button / image result button displayed on the screen. In addition, for example, as examination order information, three pieces of information of examination instruction date / time, sample collection date / time, and result registration date / time are managed, and a doctor performs examination result button by changing processing related to display according to these dates. -The examination result of the patient can be automatically displayed without using the image result button. Therefore, it is possible to help medical treatment by a doctor and to prevent omission of registration of test results.
[0064]
The confirmation method described above can also be applied in the same manner when, for example, the result of the inspection requested by the subcontracting inspection organization is referred to by an online system such as the Web. In this case, by placing an inspection result input terminal in the outsourced inspection organization and connecting the inspection result input terminal and the electronic medical record system online, it is possible to refer to the inspection result even at a remote place. It should be noted that the confirmation method described above can also be used for image diagnostic results.
[0065]
next, In other embodiments The electronic medical record system will be described with reference to an example (for example, a screen related to automatic expansion of the previous content).
[0066]
FIG. 1 is applied mutatis mutandis to show the overall configuration of the electronic medical chart system in the present embodiment. As shown in the figure, the electronic medical record system according to the present embodiment mainly includes a reception terminal 1 for performing registration and electronic medical record creation for a patient visited by a doctor, and a doctor who calls and inputs the electronic medical record of the patient. It is comprised from the terminal 2, the hub 3, and the electronic medical record server apparatus 4 which manages the electronic medical record of a registered patient.
[0067]
FIG. 5 is applied mutatis mutandis to show a display screen in the doctor terminal of the electronic medical record system in the present embodiment. As shown in the figure, so-called medical accounting delivery software (medical reminder) is installed in the doctor terminal 2 of the electronic medical record system, and the display contents (display screen) in this medical reminder are described below. It is the contents. As shown in the figure, the display screen in the medical reminder includes a display part 30 for the patient's name, gender, date of birth, etc., as well as an electronic medical chart display part 31 for showing the patient chart information, and a guidance fee for the patient. It includes a guidance fee execution information display portion 32 that shows information, and a shortcut display portion 33 that displays the shortcut, which is means for searching for medical information of the patient according to a predetermined condition. Further, the electronic medical record display part 31 includes a medical doctor display part 31a indicating the name of the medical doctor in charge regarding the patient of the electronic medical record, a finding display part 31b indicating the findings, a schema information display part 31c indicating the schema, and order information indicating the order contents. The display part 31d is configured. The doctor-in-charge display portion 31a further includes scroll buttons 310a to 310c for sequentially scrolling the electronic medical records to be displayed. Further, in the present embodiment, the shortcut display portion 33 searches for information on the display contents of the electronic medical record according to conditions such as disease name 33a, season 33b, syndrome 33c, prescription 33d, image 33e, examination 33f, and medical system 33g. It consists of multiple shortcuts. These shortcuts are displayed in different colors for each category in order to improve visibility.
[0068]
When performing a medical practice on a patient, a doctor calls the patient's electronic medical chart information from the electronic medical chart apparatus 1 using the doctor terminal 2 in which the medical reminder is installed. At this time, in the electronic medical chart system according to the present embodiment, the doctor selects / uses the previous button 310d located at the center of the display screen shown in FIG. 5 to display the previous medical contents on the screen as the current medical contents. be able to.
[0069]
For example, when a patient with a chronic disease name or a patient with hay fever is examined, the same medical practice as the previous time is often performed. Accordingly, in the case of such a revisited patient, the previous medical treatment contents are all displayed on the screen as the current contents using the previous button 310d. Then, the contents are added to the previous contents according to the current medical condition / symptoms of the patient, or the contents of the order that are no longer necessary are deleted, and used as the contents of the current medical care. If the previous medical content is exactly the same as the current medical content, the previous medical content can be directly used by selecting / using the registration button 310e located at the lower right of the display screen shown in FIG. It is also possible to confirm the current medical treatment contents to be entered in
[0070]
FIG. 7 and FIG. 11 are flowcharts for explaining the process described above along the processing of the electronic medical chart system.
[0071]
As shown in FIG. 7, when a patient comes to the hospital, patient registration and electronic medical chart creation are first performed by the reception terminal (S10). These reception registration information and electronic medical record information are stored in the electronic medical record server device (S11). When a doctor performs a medical practice on a registered patient, the doctor's terminal is used to call the patient's electronic medical record from the electronic medical record server device (S12), and information regarding the medical practice is input to the patient's electronic medical chart. (S13). The electronic medical record information is stored in the electronic medical record server device (S14).
[0072]
Thereafter, each time a medical practice is performed on the patient, the processes of S12 to S14 are repeated, and the electronic medical record information of the patient is updated.
[0073]
When performing a medical practice on the patient, the doctor selects the patient from a list of registered patients as shown in FIG. 11 using a doctor terminal installed in each clinic (S30). ). Then, the electronic medical record information regarding the patient is called from the electronic medical record server device (S31), and the electronic medical record of the patient is displayed on the display screen of the doctor terminal (S32). Here, when referring to the previous electronic medical record information related to the patient, the doctor selects / uses the previous button displayed together with the electronic medical record (S33), and the previous medical contents related to the patient are described. The electronic medical record information is called from the electronic medical record server device (S34), and the corresponding electronic medical record information is displayed on the screen (S35).
[0074]
It should be noted that when displaying the previous medical treatment contents on the screen, settings are made so that the display contents and the display method can be selected. As a variation of this setting, for example, for internal use, it is expanded every time a medical practice is performed, for specimen testing, it is expanded once a week (weekly), and for image diagnosis results, it is 1 per month. For example, it may be deployed once (only at the beginning of the month). Furthermore, these variations are set so that they can be selected for each doctor.
[0075]
The variations described above are very effective, for example, when an additional order is made for treatment for the acute stage disease name of a chronic patient.
[0076]
in this way, In this embodiment According to such an electronic medical record system, the doctor can develop the previous medical treatment contents regarding the medical patient on the screen as the current contents using the doctor terminal. Further, according to the current medical condition / symptoms of the patient, it can be used as the current electronic medical record by adding to the previous medical treatment contents or deleting unnecessary order contents. If the previous medical content is exactly the same as the current medical content, it can be used as the current medical content only by calling and confirming the previous medical content. Therefore, it is possible to reduce a burden related to the input of medical treatment contents for the doctor's electronic medical record.
[0077]
next, In other embodiments The electronic medical record system will be described with reference to an example (example: summary display of input contents and confirmation screen).
[0078]
FIG. 1 is applied mutatis mutandis to show the overall configuration of the electronic medical chart system in the present embodiment. As shown in the figure, the electronic medical record system according to the present embodiment mainly includes a reception terminal 1 for performing registration and electronic medical record creation for a patient visited by a doctor, and a doctor who calls and inputs the electronic medical record of the patient. It is comprised from the terminal 2, the hub 3, and the electronic medical record server apparatus 4 which manages the electronic medical record of a registered patient.
[0079]
As shown in FIG. 5 and FIG. 6 and as described above, the doctor inputs the contents of the medical practice into the electronic medical record and confirms the contents of the patient's medical care (symptom contents / It is necessary to confirm the contents of all of the schema diagram, order contents, disease name contents, instruction fee calculation contents, etc.). In addition to the enormous amount of these contents, the contents of the order need to be confirmed on a separate screen when the amount of information is very large. When it is necessary to confirm these contents on another screen, the doctor needs to perform this after confirming the contents by performing a plurality of operations.
[0080]
Therefore, in the electronic medical chart system according to the present embodiment, in order to simplify this confirmation operation, for example, as shown in FIG. 12, the representative content 51 of each section of the order, the information 52 of the calculated insurance, the information of the effective disease name 53, Information on guidance fees, telephone reexaminations, home visits, etc. delivered to medical accounting (indicated as medical reminder in Fig. 12) 54 Medical treatment contents (information necessary to confirm the input to the electronic medical record system) By adding an integrated display screen 50 that integrates and displays the information to the new display contents, the doctor can easily determine the medical contents in the electronic medical record system.
[0081]
After completing the input of the medical treatment contents to the electronic medical record regarding the medical patient, the doctor displays the integrated display screen 50 on the screen and confirms the contents. Since the medical treatment contents displayed on the integrated display screen 50 are integrated contents as shown in FIG. 12, the doctor can easily check the contents. In this way, after confirming the contents, the doctor confirms the electronic medical record information related to the medical patient (by selecting / using the registration button 310e described above, the doctor confirms the electronic medical record information). Can do.) Electronic medical record information relating to the medical patient is stored in the electronic medical record server device 4.
[0082]
In addition to this, the integrated display screen 50 also includes, for example, a disease name button 55 for inputting an effective disease name, a healing button 56 for deleting registration of a valid disease name, and continuing to register an effective disease name. A button 57, a return button 58 for deleting the display of the integrated display screen 50, and the like are displayed.
[0083]
in this way, In this embodiment According to such an electronic medical record system, when a doctor confirms the medical treatment content input to the electronic medical record, the content can be easily confirmed by displaying an integrated display screen on which the input information is integrated and displayed. Therefore, it is possible to save time and effort related to the confirmation when the doctor confirms the input contents of the electronic medical record.
[0084]
【The invention's effect】
As described above, according to the electronic medical record system according to the present invention, since the electronic medical record information related to the patient and the shortcut function are associated with each other, the doctor uses the shortcut function to display the information for each applicable condition. Painting On the surface Simultaneous display with the electronic medical record information can do. Furthermore, by creating a new electronic medical record using such a template, it is possible to reduce the burden on the doctor's input of the electronic medical record.
[Brief description of the drawings]
FIG. 1 is a system configuration diagram of an electronic medical chart system according to the present invention.
FIG. 2 is a flowchart illustrating a flow from reception registration of a patient at a reception terminal of the electronic medical record system in the first embodiment to creation / storage of a queue.
FIG. 3 is a flowchart for explaining a flow from search to display of a medical patient in a doctor terminal of the electronic medical record system according to the first embodiment.
FIG. 4 is a diagram illustrating a configuration example of a database relating to simplification of an electronic medical record input method (medical practice input method) in a doctor terminal of the electronic medical record system according to the first to third embodiments.
FIG. 5 is a diagram showing a display screen on a doctor terminal of the electronic medical record system in the second to fifth embodiments.
6 is a diagram showing a display screen after using a shortcut in the display screen shown in FIG. 5. FIG.
FIG. 7 is a flowchart for explaining a flow from registration of a visit patient at the reception terminal of the electronic medical record system according to the second embodiment to input of the patient's electronic medical record information at the doctor terminal.
FIG. 8 is a flowchart for explaining a flow until an electronic medical record information is called by a shortcut of a medical patient in a doctor terminal of the electronic medical record system according to the second embodiment.
FIG. 9 is a diagram showing an example of a test result display screen displayed after using the test result button on the display screen shown in FIG. 5 in the doctor terminal of the electronic medical record system according to the third embodiment.
FIG. 10 is a flowchart regarding automatic reference of examination results (image diagnosis results) of a medical patient in a doctor terminal of the electronic medical record system according to the third embodiment.
FIG. 11 is a flowchart for explaining a flow from calling a medical patient's electronic medical record information at the doctor terminal of the electronic medical chart system according to the fourth embodiment to calling the previous electronic medical record information of the medical patient.
FIG. 12 is a diagram showing a summary display and confirmation screen of the input contents of a medical patient's electronic medical record in a doctor terminal of the electronic medical record system according to the fifth embodiment.
[Explanation of symbols]
1 ... Reception terminal
2 ... Doctor terminal
3 ... Hub
4 ... Electronic medical record server device
10 ... Medical set master
11 ... Prescription set master
12 ... Injection set master
13 ... Treatment set master
14 ... Inspection set master
15 ... Image set master
16 ... Rehabilitation reset master
17 ... Meal set master
18 ... reminder master
20 ... Master complaint / finding template master
21 ... Schema master
22 ... Disease name master
30 ... Patient information display part
31 ... Electronic chart display part
31a ... The doctor's display
31b ... Observation display part
31c: schema information display part
31d: Order information display part
310a to 310c ... scroll buttons
310d ... last time button
310e ... Registration button
32 ... Instruction fee implementation information display part
33 ... Shortcut display part
33a-33g ... Shortcut
34 ... Character recognition part
35 ... Test result button
36 ... Image result button

Claims (3)

In an electronic medical chart system that includes a database, a display unit, an input means, and a control means, and creates an electronic medical record that records medical treatment contents related to a patient's medical care,
The database has storage means in which electronic medical record information including a disease name information item and a plurality of medical care information items and a plurality of shortcut names that are individual components of the electronic medical record information are stored in association with each other,
The control means displays the electronic medical chart information and the plurality of shortcut names on the display section, and refers to the database based on the selection instruction of the shortcut name by the input means. A control unit that performs control for simultaneously displaying the medical treatment contents of the patient associated with the shortcut name together with the electronic medical record information and presenting it as a template of a new electronic medical record;
An electronic medical chart system characterized by The shortcut name, component a is formulation practice, injection, treatment, testing, electronic medical record system of claim 1, wherein a is a multiple one of the image. The shortcut name, electronic medical record system of claim 1, wherein seasonal epidemics Disease, Syndrome another, chronic disease name, to be a multiple one of frequent order.

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