JP5061646B2 - Electronic medical record creation support program, apparatus, and processing method - Google Patents

Description

  The present invention relates to an electronic medical record creation support program. In particular, it is necessary for information input to the electronic medical record created when medical treatment is ongoing from a plurality of information input tool program groups prepared in advance in the process of creating an electronic medical record using a plurality of information input tool programs. The present invention relates to a technology that activates one or a plurality of input tools to support electronic medical record creation processing.

  In recent years, electronic medical records in which medical information is recorded as electronic data have been adopted instead of paper medical records. The doctor / dentist creates an electronic medical record describing medical information such as a patient name, a disease name, main symptoms, and a treatment method (prescription and treatment) for each medical treatment using a predetermined terminal or the like.

  When inputting information into the electronic medical record, various information input processing programs (information input tools) are activated and used according to the input information.

  For example, when a doctor inputs a finding in an electronic medical record, a template of information described in the finding is prepared, and a finding input tool that can input arbitrary text data is activated and used by using the finding input template.

  In addition, when inputting a treatment, a treatment input set in which a combination of treatments that are likely to be performed at the same time is set is prepared, or a treatment slip tool capable of inputting a frequently performed treatment is started. .

  In addition, when entering prescription (medicine) information, prescription information can be entered using a medication set in which the drugs to be administered and their usage are set based on the drug name database, or frequently administered. Or launch a medication slip tool that allows you to enter the medicine you want.

  In order to input information into the electronic medical chart created for each medical treatment, it is necessary to start the information input tool program according to the input items, and the burden of input work has become excessive. Therefore, the techniques disclosed in Patent Documents 1 and 2 are known in order to reduce the burden of inputting information to the electronic medical record.

  In Patent Document 1, medical information such as a treatment method is registered as a set based on a disease name, and when the medical information is input to another electronic medical record, the registered set can be reused. As a result, the work load of the electronic medical record preparation process is reduced.

In Patent Document 2, the disease name and the input tool set are stored in association with each other, and when a new disease name is input in the electronic medical record creation process, the input tool set associated with the corresponding disease name is activated to We are trying to reduce the burden of input work to the chart.
JP 2000-259740 A JP 2006-139389 A

  In general, patients visit multiple times for treatment. An electronic medical record for each medical treatment needs to be created. Therefore, the number of cases where an electronic medical record is created in continuous medical care under the same disease name is much greater than the case where a new disease name is recorded and an electronic medical record is created.

  However, during ongoing treatment, even if the name of the disease is the same and the content of the same visit (diagnosis, examination, medication, rehabilitation, etc.), the content of the treatment is different between the early stage and the later stage. Different information. Therefore, the information input tool used in the electronic medical record creation process may be different.

  The conventional system can support the information input work to the electronic medical record in the case of medical care in which a new disease name is input. However, when continuous medical care is provided for chronic illnesses, for example, repetitive treatment such as rehabilitation, dialysis, and repetitive treatment, preparation of electronic medical records for diseases that require continuous prescription, Only the same information input process as in the case of new medical treatment was possible.

  An object of the present invention is to provide a processing technique for enabling an information input operation to be easily performed on an electronic medical record when an electronic medical record is created for continuous medical care.

  The present invention is a program, a processing apparatus, and a processing method for supporting processing for creating an electronic medical record in which medical information is recorded using a plurality of information input tool programs.

  The present invention provides master information (tool set information) that combines information input tools (for example, finding input templates, treatment slip tools, medication slip tools, etc.) used in electronic medical record creation processing according to the name of the disease and the contents of the visit. ) In advance. Tool set information may be created and saved.

  Then, when creating an electronic medical chart, the tool set information is referred to according to the patient's disease name and the contents of the medical examination, and the optimal information input tool corresponding to the patient's examination is identified and activated, and the electronic medical chart creation processing system automatically To be deployed.

  Since the doctor can input various information to the electronic medical chart by using the information input tool automatically developed, the information input work can be simplified.

  Also, in an electronic medical record creation processing system, various information input tools can usually be activated and used by manual operation. Therefore, after the completion of the electronic medical record creation, the information input tool used in the creation process is specified, and the new tool set information is created and stored for the information input tool, the disease name, and the contents of the examination.

  In addition, it is possible to edit tool set information by taking out arbitrary tool set information and adding, deleting, or changing a set information input tool.

  The doctor can prepare a combination of information input tools that may be used in subsequent examinations according to the patient's medical condition.

Specifically, the computer to which the present invention is realized, and tools storage unit for storing a plurality of information input tool program for an information input processing to the electronic medical record, one or used during information input process of electronic medical record A plurality of information input tool programs are set , and the tool set information storage unit stores the tool set information in which the disease name information and the continuation classification information indicating whether the medical treatment for the disease name is new or continued, and the medical treatment is performed. A patient disease name information storage unit storing patient disease name information in which a disease name of each patient and an outcome of the disease name are set. The processing unit includes a reception patient reference unit, a patient disease name reference unit, a tool set reference unit, and a tool activation unit.

  The reception patient reference unit of the computer obtains the reception information in which the patient who has received the diagnosis and the details of the received reception are set, and the patient disease name information matching the patient in the reception information is obtained from the patient disease name information storage unit. Extract. The patient disease name reference unit extracts a disease name from the extracted patient disease name information from the patient disease name information in which information indicating that medical treatment is ongoing is set as an outcome.

The tool set reference unit, said to indicate patient disease name reference unit outcome in clinical continued extracted patient disease name information, extracts the toolset information indicating continuation the continuation sorting information name of the disease is match, Get the information input tool program set in the extracted tool set information . Then, the tool activation unit activates the acquired information input tool program among the information input tool programs stored in the tool storage unit.

  As a result, when an electronic medical record is created during an examination for an ongoing disease, the information input tool program required for information entry is identified and started from the tool set information registered based on the patient's disease and the contents of the examination. can do. Then, the activated information input tool program can be expanded to simplify the information input process in many cases of the electronic medical record creation process. For example, it is possible to simplify the process of creating an electronic medical record for routine medical treatment such as medication, rehabilitation, and dialysis, which can be repeated, thereby reducing the work load of the electronic medical record preparation process.

  Furthermore, the computer may include a tool set registration unit.

  When the electronic medical record is created, the tool set registration unit identifies all information input tool programs used for inputting information of the electronic medical record, and is recorded in the specified information input tool program and the electronic medical record. The tool set information in which the name of the disease and the contents of the consultation are set may be created and registered in the tool set information storage unit. As a result, the combination of information input tools used in the electronic medical record creation process can be registered, and information input can be simplified in the next electronic medical record creation process for the same disease name and medical examination contents.

  The tool set registration unit may create tool set information including patient specifying information of the electronic medical record when the electronic medical record is created. This makes it easy to create an electronic medical record that matches the patient's medical condition.

  The program of the present invention can be stored in an appropriate recording medium such as a portable medium readable by a computer, a semiconductor memory, and a hard disk, and is provided by being recorded on these recording media or via a communication interface. Provided by transmission and reception using various communication networks.

  According to the present invention, when creating an electronic medical chart, it is possible to select and expand an information input tool corresponding to a patient's disease name and medical examination contents by referring to the tool set information stored corresponding to the patient's disease name and medical examination contents. It is possible to simplify the information input operation to the electronic medical record of the doctor.

  In addition, after the completion of the electronic medical record creation, the information input tool used in the electronic medical record creation processing can be identified and saved together with the disease name and the contents of the medical examination. In addition, the tool set can be edited by adding or deleting an information input tool based on the existing tool set information.

  This makes it possible to prepare a combination of information input tools that may be used in subsequent examinations according to the progress of the medical condition for each patient. It can be simplified.

  FIG. 1 is a diagram showing a configuration example in the best embodiment of the present invention.

  The electronic medical record creation system in which the present invention is implemented includes an electronic medical record server 1 and a plurality of electronic medical record terminals 2. The electronic medical record input support apparatus 20 according to the present invention is incorporated in each electronic medical record terminal 2 (a computer including a CPU and a memory).

  The electronic medical record server 1 is a database that stores and manages various information. The electronic medical record server 1 includes a tool master table 11, a disease name master table 12, a consultation content master table 13, a tool set master table 14, a medical record data table 15, a patient disease name table 16, and a reception information table 17.

  The tool master table 11 is a data table in which an information input tool, which is a program for performing an information input process, used in the electronic medical record creation process is registered.

  FIG. 2 is a diagram illustrating a data configuration example of the tool master table 11. In the tool master table 11, for each information input tool, a tool number for identifying the information input tool, a tool name of the information input tool, and a tool content indicating the processing content of the information input tool are registered.

  For example, tool number = 001-001, tool name = fracture 1 indicates a treatment slip tool used in the electronic medical record creation process when a fracture is diagnosed. Tool number = 002-002, tool name = slip (anemia / vertigo) indicates a treatment slip tool used in the electronic medical record creation process when anemia is diagnosed. Tool number = 003-001, tool name = Do (prescription) indicates a medication slip tool used in the electronic medical record creation process when the same prescription as the previous one is performed.

  The disease name master table 12 is a data table in which disease names used in the electronic medical record creation process are registered. The disease name is the name of a disease diagnosed by a doctor, and diabetes, acute upper respiratory tract inflammation, gastric ulcer, etc. are registered.

  FIG. 3 is a diagram illustrating a data configuration example of the disease name master table 12. In the disease name master table 12, a disease name code for identifying a disease name and a disease name indicating the name of the disease are registered for each disease.

  The medical examination content master table 13 is a data table in which medical examination contents used in the electronic medical record creation process are registered. The contents of the medical examination are the contents of the medical care that the patient declared at the time of reception or that was actually performed, and for example, examination, examination, injection, medication, rehabilitation (rehabilitation), etc. are registered.

  FIG. 4 is a diagram illustrating a data configuration example of the consultation content master table 13. In the consultation content master table 13, a consultation content code for identifying the consultation content and a consultation content name are registered for each consultation content.

  The tool set master table 14 is a data table in which tool set information relating to a combination (tool set) of information input tools used in the electronic medical record creation process is registered.

  FIG. 5 is a diagram illustrating a data configuration example of the tool set master table 14. The tool set master table 14 is expanded for each tool set, together with the tool set number for identifying the tool set, the tool set name, and the tool set contents indicating one or more information input tools constituting the set. As information recorded in the electronic medical record, a disease name code of the electronic medical record, a disease name, a continuation category indicating whether the medical treatment is new or continuation, contents of the medical examination, and creation date of the electronic medical record are registered. When the tool set is registered for a specific patient, a patient ID for specifying the patient and a disease name order number indicating a specific disease name of the specific patient are further registered.

  For example, “tool set number = 003 (fracture rehabilitation)”, which is the third row record from the top of the tool set master table 14 in FIG. 5, is a disease name = shoulder fracture (disease name code = 31301), continuation category = continuation, consultation When the content = rehabilitation, the information input tool group specified by the tool set content = 001-001 (see FIG. 2) is used in the electronic medical record creation process.

  In addition, “tool set number = 004 (gastric ulcer (medicine))”, which is the sixth row record from the top, is a specific disease name (stomach ulcer (disease name) for a specific patient (patient ID = 0000000021) according to disease name order number = 00000002765. For code = 77154)), the information input tool group specified by the tool set content = 003-001 (see FIG. 2) is used in the electronic medical record preparation process when the continuation category = continuation and consultation content = medicine. It shows that.

  Thus, by setting the disease name order number registered in the patient disease name table 16 described later, a specific tool set can be registered in association with the patient and the disease name.

  The chart data table 15 is a data table in which information for identifying the created electronic chart is registered.

  FIG. 6 is a diagram illustrating a data configuration example of the chart data table 15. The chart data table 15 is recorded in the chart for each patient, the patient ID for identifying the patient, the name of the patient, the medical department (department) that has been consulted, and the medical record serial number indicating the order in which there are multiple electronic medical charts. The medical chart contents, which is the recorded information, are registered.

  The patient disease name table 16 is a data table in which patient disease name information related to the disease name of each patient extracted from the created electronic medical record is registered.

  FIG. 7 is a diagram illustrating a data configuration example of the patient disease name table 16. The patient disease name table 16 includes, for each data extracted from the created electronic medical record, a disease name order number that identifies the data, a disease name code that identifies the extracted disease name, a disease name, a patient ID that identifies the patient, a patient name, Outcomes that indicate the course of the disease (healing, continuation, etc.) are registered.

  For example, the third data from the top of the patient disease name table 16 in FIG. 7 indicates that the disease of the patient name = Adachi Saburo (disease name = acute upper respiratory tract inflammation) is “cured”. The fourth data shows that the patient name = Saburo Adachi's disease (sick name = shoulder fracture) is “treatment is ongoing”.

  The reception information table 17 is a data table in which reception information created at reception is registered.

  FIG. 8 is a diagram illustrating a data configuration example of the reception information table 17. In the reception information table 17, for each reception, a reception number (reception No) for identifying the reception, a medical examination department (department) indicating a medical department to receive medical examination, a patient ID for identifying a received patient, a patient name, a reception time, a medical examination The contents of the medical examination showing the contents of the medical care to be performed and the current waiting state are registered. The waiting state includes a state in which the reception process has been completed (accepted), a state in which medical care has been completed (consulted), and a state in which payment of medical expenses has been completed (accounted).

  FIG. 9 is a diagram illustrating a configuration example of the electronic medical record input support device 20 incorporated in each electronic medical record terminal 2.

  The electronic medical record input support device 20 includes a reception patient reference unit 21, a medical record creation unit 22, a patient disease name reference unit 23, a tool set reference unit 24, a tool activation unit 25, a medical record storage unit 26, and a patient disease name configured by a software program or the like. A registration unit 27 and a tool set registration unit 28 are provided.

  The reception patient reference unit 21 is a processing unit that refers to the reception information table 17 and acquires reception information.

  The chart creation unit 22 is a processing unit that creates an electronic chart.

  The patient disease name reference unit 23 extracts the patient name information (patient disease name information) of the received information from the patient disease name table 16 using the patient ID of the received information acquired by the received patient reference unit 21 as a key, and the extracted patient This is a processing unit that extracts a patient's disease name from the patient disease name information in which information indicating that medical treatment is ongoing is set as the outcome among the disease name information.

  The tool set reference unit 24 is a processing unit that extracts, from the tool set master table 14, tool set information having the same consultation contents and disease names, and acquires an information input tool set in the tool set contents of the tool set information. is there.

  The tool activation unit 25 is a processing unit that activates the information input tool specified by the tool set reference unit 24 and develops it in conjunction with the chart creation unit 22.

  The chart storage unit 26 is a processing unit that stores the electronic chart created by the chart creation unit 22 in the chart data table 15.

  The patient disease name registration unit 27 creates patient disease name information such as the disease name and outcome of each patient recorded in the electronic medical record based on the electronic medical record created by the medical record creation unit 22 and registers it in the patient disease name table 16 Part.

  The tool set registration unit 28 identifies the information input tool developed by the chart creation unit 22, creates tool set information in which the identified information input tool, the disease name registered in the electronic medical record, the contents of the examination, and the like are set. It is a processing unit registered in the set master table 14. The tool set registration unit 28 may create tool set information including a patient ID and a disease name order number.

  10 and 11 show the overall processing flow of the present invention.

  The reception patient reference unit 21 activates the reception patient list screen 100 indicating the reception information of the currently received patient from the electronic medical record creation system (step S1). FIG. 12 is a diagram showing a received patient list screen example 100. The reception patient list screen 100 includes the reception information of the reception information table 17, reception number (reception No), reception time, medical department (department), patient information (name, gender, age), medical examination contents, The waiting state is displayed.

  The received patient reference unit 21 selects a patient for whom an electronic medical record is to be created on the received patient list screen 100 and presses the “create chart” button 110 (step S2). In the received patient list screen example 100 of FIG. 12, when the patient with the reception number = 4 is selected and the “Create chart” button 110 is pressed, electronic chart creation processing is performed for the patient's medical care.

  The medical record creation unit 22 refers to the medical record data table 15 and develops an electronic medical record in which the consultation information of the patient selected by the reception patient reference unit 21 is set (step S3).

  The tool set reference unit 24 refers to the tool set master table 14 and executes a subroutine SR1 for searching for the presence of the tool set information of the patient (step S4).

  FIG. 13 is a processing flow of the subroutine SR1.

  The tool set reference unit 24 determines whether there is a record in the tool set master table 14 that matches the reception information of the patient who developed the electronic medical record with the “consultation content” and “patient ID” (step S41).

  If there is a matching record (YES in step S42), the patient name table 16 is referred to, and the “patient ID” matches the patient whose chart has been developed, and the “disease name order number” in which “outcome” is “continue”. To get. Then, it is determined whether there is a record in which the acquired “disease name order number” matches the “disease name order number” of the record in the tool set master table 14 acquired in step S41 (step S43).

  If a record exists (YES in step S44), “exists” is returned (step S45). If no record exists (NO in step S44), “does not exist” is returned (step S46). Exit.

  In the processing flow of FIG. 10, if there is a patient tool set in the process of subroutine SR1 (YES in step S5), the tool activation unit 25 selects an information input tool group (tool set) constituting the corresponding tool set. , The tool master table 11 is referred to and activated to expand the tool set (step S6).

  On the other hand, if the patient tool set does not exist in the process of the subroutine SR1 (NO in step S5), the subroutine SR2 for searching for general tool set information is executed (step S7).

  FIG. 14 is a processing flow of the subroutine SR2.

  The tool set reference unit 24 refers to the patient disease name table 16 and acquires a “disease name code” in which “patient ID” matches the patient who developed the electronic medical record and “outcome” is “continuation” (step S71). . It is determined whether or not there is a record in the tool set master table 14 that matches the “disease name code” acquired in the process of step S71 and that matches the “checkup status” of the patient who developed the electronic medical record (step S72). ). Here, a record in which “disease name code” is blank in the tool set master table 14 is treated as being equal to all disease name codes, and determination processing is performed. Further, in the tool set master table 14, a record in which “checkup status” is blank is treated as being equal to the total checkup status, and determination processing is performed.

  If the tool set exists in the subroutine SR2 (YES in step S8), the tool activation unit 25 activates each information input tool constituting the corresponding tool set with reference to the tool master table 11, and the tool The set is expanded (step S6).

  Then, the developed electronic medical record is written using the tool set (step S9).

  FIG. 15 is a diagram illustrating a display example in which the information input tool is expanded on the electronic medical record input screen 200. When a record of a general tool set for fracture rehabilitation (tool set number = 003) is hit from the tool set master table 14 shown in FIG. 5, “fracture 1 (001-001) registered in the tool master table 11 is found. 001) "treatment input template is expanded. The treatment template window 210 for the fracture 1 is displayed on the electronic medical record input screen 200, and the information input in the window 210 is processed as information input to the treatment / prescription column 220.

  Thereafter, when it is recognized in the examination that there is a change in the medical condition of the patient, it is determined whether or not the information input tool used in the electronic medical record creation process is changed (step S10). When the information input tool to be used is changed (YES in step S11), a subroutine SR3 for registering tool set information for each patient is executed (step S12).

  FIG. 16 is a processing flow of the subroutine SR3.

  The tool set registration unit 28 obtains currently applied tool set information (a record of the tool set master table 14) regarding the patient to register the tool set (step S121), and a tool set master maintenance screen as shown in FIG. 300 is displayed (step S122). In the tool set master maintenance screen 300 of FIG. 17, information input tools constituting the current tool set contents are displayed on the applied tool set 310. In addition, all information input tools registered in the tool master table 11 are displayed in the tool list 320.

  The tool set registration unit 28 selects an information input tool to be used when creating an electronic medical record in future medical care from the tool list 320 on the tool set master maintenance screen 300, and is selected when the right arrow button 330 is pressed. The information input tool is copied and registered in the application tool set 310 (step S123).

  When the “save” button 350 on the tool set master maintenance screen 300 is pressed and the applied tool set 310 is updated (YES in step S124), the tool set information (record) being edited is updated (step S125). On the other hand, when the “Cancel” button 370 on the tool set master maintenance screen 300 is pressed (NO in step S124), the application tool set registration process is stopped.

  Although the present invention has been described above with reference to the embodiments, it is obvious that the present invention can be variously modified within the scope of the gist thereof.

  For example, in the present embodiment, the electronic medical record input support device 20 has been described as being implemented as a device that includes the medical record creation unit 22 and the medical record storage unit 26. However, without providing these processing units, an information input tool that can be developed by an electronic medical record creation processing unit linked with the present invention may be activated only by an activation request or the like.

  The features of the embodiments and examples of the present invention are listed as follows.

(Appendix 1)
To support the process of creating electronic medical records with medical information recorded using multiple information input tool programs,
A tool storage unit for storing a plurality of information input tool programs for performing information input processing to an electronic medical record;
A tool set information storage unit that stores tool set information in which a disease name recorded in an electronic medical record, a medical examination content, and one or a plurality of information input tool programs used during information input processing of the electronic medical record are stored;
A patient disease name information storage unit in which the disease name information of each patient who has performed medical care and the patient disease name information in which the outcome of the disease name is set;
A patient who has received an examination, an acceptance information in which the contents of the accepted examination are set, and an acceptance patient reference unit that extracts patient disease name information that matches the patient of the acceptance information from the patient disease name information storage unit;
Among the extracted patient disease name information, a patient disease name reference unit that extracts a disease name from patient disease name information in which information indicating that medical treatment is ongoing is set as an outcome;
From the tool set information storage unit, the latest stored tool set information that matches the contents of the reception information received and the extracted disease name is extracted, and the information input tool program set in the tool set is acquired. A tool set reference,
Among the information input tool programs stored in the tool storage unit, as a device comprising a tool activation unit that activates the acquired information input tool program,
An electronic medical record creation support program that allows computers to function.

(Appendix 2)
When the electronic medical record is created, all the information input tool programs used for information input of the electronic medical record are specified, and the specified information input tool program, the disease name recorded in the electronic medical record, and the contents of the examination are displayed. The electronic medical record creation support program according to Appendix 1, further comprising a tool set registration unit that creates set tool set information and registers the tool set information in the tool set information storage unit.

(Appendix 3)
The electronic medical record creation support program according to appendix 2, wherein the tool set registration unit creates tool set information including patient specifying information of the electronic medical record when the electronic medical record is created.

(Appendix 4)
The tool set registration unit creates new tool set information by adding or deleting an information input tool program of tool set information stored in the tool set information storage unit. The electronic medical record creation support program according to claim 1.

(Appendix 5)
To support the process of creating electronic medical records with medical information recorded using multiple information input tool programs,
A tool storage unit for storing a plurality of information input tool programs for performing information input processing to an electronic medical record;
A tool set information storage unit that stores tool set information in which a disease name recorded in an electronic medical record, a medical examination content, and one or a plurality of information input tool programs used during information input processing of the electronic medical record are stored;
A patient disease name information storage unit in which the disease name information of each patient who has performed medical care and the patient disease name information in which the outcome of the disease name is set;
A patient who has received an examination, an acceptance information in which the contents of the accepted examination are set, and an acceptance patient reference unit that extracts patient disease name information that matches the patient of the acceptance information from the patient disease name information storage unit;
Among the extracted patient disease name information, a patient disease name reference unit that extracts a disease name from patient disease name information in which information indicating that medical treatment is ongoing is set as an outcome;
From the tool set information storage unit, the latest stored tool set information that matches the contents of the reception information received and the extracted disease name is extracted, and the information input tool program set in the tool set is acquired. A tool set reference,
An electronic medical record creation support apparatus comprising: a tool activation unit that activates the acquired information input tool program among the information input tool programs stored in the tool storage unit.

(Appendix 6)
A computer having a tool storage unit for storing a plurality of information input tool programs for performing an information input process on an electronic medical record creates an electronic medical record on which medical information is recorded using a plurality of information input tool programs. A processing method executed to assist,
Patient disease name information storage in which the patient who has received the examination, the reception information in which the contents of the accepted examination are set, and the patient name information in which the name of each patient who has been treated and the outcome of the disease name is set are stored Receiving patient reference process for extracting patient disease name information matching the patient of the reception information from the department;
Among the extracted patient disease name information, a patient disease name reference process for extracting a disease name from the patient disease name information in which information indicating that medical treatment is ongoing is set as an outcome;
From the tool set information storage unit that stores the tool name information in which one or more information input tool programs used at the time of information input processing of the disease name recorded in the electronic medical record and the information input process of the electronic medical record are stored, A tool set reference process for extracting the latest memorized tool set information that matches the consultation contents of the reception information and the extracted disease name, and obtaining an information input tool program set in the tool set;
An electronic medical record creation support processing method comprising: a tool activation processing step of activating the acquired information input tool program among the information input tool programs stored in the tool storage unit.

It is a figure which shows the structural example in the best embodiment of this invention. It is a figure which shows the data structural example of a tool master table. It is a figure which shows the example of a data structure of a disease name master table. It is a figure which shows the data structural example of a consultation content master table. It is a figure which shows the data structural example of a tool set master table. It is a figure which shows the data structural example of a medical chart data table. It is a figure which shows the example of a data structure of a patient disease name table. It is a figure which shows the data structural example of a reception information table. It is a figure which shows the structural example of the electronic medical record input assistance apparatus integrated in the electronic medical record terminal. It is the whole processing flow of this invention. It is the whole processing flow of this invention. It is a figure which shows the example of a reception patient list screen. It is a processing flow of subroutine SR1. It is a processing flow of subroutine SR2. It is a figure which shows the example of a display by which the information input tool is expand | deployed in the electronic medical record input screen. It is a processing flow of subroutine SR3. It is a figure which shows the example of a tool set master maintenance screen.

Explanation of symbols

DESCRIPTION OF SYMBOLS 1 Electronic medical record server 2 Electronic medical record terminal 11 Tool master table 12 Disease name master table 13 Consultation content master table 14 Tool set master table 15 Medical record data table 16 Patient disease name table 17 Reception information table 20 Electronic medical record input support device 21 Reception patient reference part 22 Medical chart creation unit 23 Patient disease name reference unit 24 Tool set reference unit 25 Tool activation unit 26 Medical record storage unit 27 Patient disease name registration unit 28 Tool set registration unit

Claims (5)

To support the process of creating electronic medical records with medical information recorded using multiple information input tool programs,
A tool storage unit for storing a plurality of information input tool programs for performing information input processing to an electronic medical record;
Electronic is set chart of an information input processing at one or more of the information used in the input tool program, disease name information and toolset information care for the name of the disease is associated with continued division information indicating whether new or continued storage A tool set information storage unit,
A patient disease name information storage unit in which the disease name information of each patient who has performed medical care and the patient disease name information in which the outcome of the disease name is set;
A patient who has received an examination, an acceptance information in which the contents of the accepted examination are set, and an acceptance patient reference unit that extracts patient disease name information that matches the patient of the acceptance information from the patient disease name information storage unit;
Among the extracted patient disease name information, a patient disease name reference unit that extracts a disease name from patient disease name information in which information indicating that medical treatment is ongoing is set as an outcome;
If the outcome of the patient disease name information which the patient disease name reference section is extracted by indicating that the medical care continues to extract the toolset information indicating continuation the continuation sorting information Disease match is set to the extracted tool set information A tool set reference section to obtain the information input tool program
Among the information input tool programs stored in the tool storage unit, as a device comprising a tool activation unit that activates the acquired information input tool program,
An electronic medical record creation support program that allows computers to function. When the electronic chart is created, toolset to identify all information input tool program used in the information input of the electronic chart, the identified information input tool program, sets the disease name information and continue sorting information The electronic medical record creation support program according to claim 1, further comprising a tool set registration unit that creates information and registers the information in the tool set information storage unit. The electronic medical record creation support program according to claim 2, wherein the tool set registration unit creates tool set information including patient specifying information of the electronic medical record when the electronic medical record is created. To support the process of creating electronic medical records with medical information recorded using multiple information input tool programs,
A tool storage unit for storing a plurality of information input tool programs for performing information input processing to an electronic medical record;
Electronic is set chart of an information input processing at one or more of the information used in the input tool program, disease name information and toolset information care for the name of the disease is associated with continued division information indicating whether new or continued storage A tool set information storage unit,
A patient disease name information storage unit in which the disease name information of each patient who has performed medical care and the patient disease name information in which the outcome of the disease name is set;
A patient who has received an examination, an acceptance information in which the contents of the accepted examination are set, and an acceptance patient reference unit that extracts patient disease name information that matches the patient of the acceptance information from the patient disease name information storage unit;
Among the extracted patient disease name information, a patient disease name reference unit that extracts a disease name from patient disease name information in which information indicating that medical treatment is ongoing is set as an outcome;
If the outcome of the patient disease name information which the patient disease name reference section is extracted by indicating that the medical care continues to extract the toolset information indicating continuation the continuation sorting information Disease match is set to the extracted tool set information A tool set reference section to obtain the information input tool program
An electronic medical record creation support apparatus comprising: a tool activation unit that activates the acquired information input tool program among the information input tool programs stored in the tool storage unit. A computer having a tool storage unit for storing a plurality of information input tool programs for performing an information input process on an electronic medical record creates an electronic medical record on which medical information is recorded using a plurality of information input tool programs. A processing method executed to assist,
Patient disease name information storage in which the patient who has received the examination, the reception information in which the contents of the accepted examination are set, and the patient name information in which the name of each patient who has been treated and the outcome of the disease name is set are stored Receiving patient reference process for extracting patient disease name information matching the patient of the reception information from the department;
Among the extracted patient disease name information, a patient disease name reference process for extracting a disease name from the patient disease name information in which information indicating that medical treatment is ongoing is set as an outcome;
Electronic is set chart of an information input processing at one or more of the information used in the input tool program, disease name information and toolset information care for the name of the disease is associated with continued division information indicating whether new or continued storage from toolset information storage unit, extracts the patient disease name when patient outcomes disease name information extracted by the reference process indicating that the medical care continues, the tool set information indicating the continuous segment information name of the disease is consistent continuation A tool set reference process for obtaining an information input tool program set in the extracted tool set information ,
An electronic medical record creation support processing method comprising: a tool activation processing step of activating the acquired information input tool program among the information input tool programs stored in the tool storage unit.

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