JP5436762B2 - Medical information input device - Google Patents

Description

  The present invention relates to a medical assistance device or an electronic medical record device that records medical information of a patient, and more particularly to an apparatus and method that can easily input medical data that is often input in sentences such as main complaints and symptoms.

  In a medical institution, a medical assistance device so-called an electronic medical record device that records the treatment contents and the like for a patient is becoming widespread. In this medical assistance device, the patient's name of the sickness, the chief complaint of the patient, the findings of the doctor, the data of the doctor, etc., and the treatment contents such as the treatment, prescription, examination, etc. performed on the patient are examined. Record the medical data that you represent. In the conventional medical support device, there are a disease name input task for inputting the name of the wound, a prescription input operation for inputting treatment, prescription, etc., and a main complaint, finding, progress input operation for inputting progress data, etc. Usually prepared.

  FIG. 11 shows an example of a chart 2 paper screen 80 that displays medical data in the medical assistance device. There is a paper that records daily medical practice called a medical chart No. 2 in the paper chart, and the screen is configured to resemble it. The right side of the screen is a prescription display area 83 for inputting and displaying a medical practice performed on a patient such as treatment, prescription, and examination. On the left side is a progress display area 82 for inputting and displaying a disease name, chief complaint, findings, and the like. Since the medical data is usually recorded in units of medical days visited by the patient and treated, the past data is designated and displayed from the medical day list 81 on the left side of the screen.

  The medical chart should be written so that it is easy to see what is written when it is referred to later. Also, it should be written on the premise that others will see it. This is the same for both handwritten and electronic medical records. Therefore, in the medical assistance device, it is recorded so that the input medical data can be identified, and a label is attached so that it can be understood even when it is called and displayed. doing. For example, when recording body temperature data, a label “body temperature”, an actually measured value such as “37.6”, and a unit “° C.” are recorded together. However, it is troublesome for doctors to enter “body temperature”, “° C.”, etc., so in the past, when entering clinical data, a standard input frame called a template was prepared for each item such as body temperature input or blood pressure input. However, only the actual measurement value has to be input there. See, for example, US Pat.

  FIG. 7 shows an example of a screen for inputting data such as progress. This is a progress input screen 40 that is activated and displayed in response to a user instruction on the No. 2 paper screen 80. This figure shows a state in which a doctor further calls and displays a template prepared for each item in order to input the main complaint history, past history, body temperature and pulse data.

There are templates that input numerical data such as body temperature and pulse, and templates that input text such as chief complaint and current medical history. In order to avoid entering long sentences each time, or so that input processing can be performed only with a pointing device such as a mouse device or a touch pen, sentences that are frequently input are registered in advance as fixed phrases and phrases. The method of selecting and entering was taken. These fixed phrases and phrases are stored in several categories, such as those related to the chief complaint / current medical history, basic medical information, and information specific to the first visit, as shown in the figure. ing. Therefore, in the tree view that displays “standard phrases / phrases” on the left side of the screen, open the main complaint / current medical history folder among the folders on the left side, and select the fixed phrase displayed in the list on the right side. The template is input to the template. After that, push the OK button to register the medical data. Thereby, the data input here is reflected and displayed on the chart No. 2 paper screen 80. In this specification, a phrase refers to a word or a relatively short sentence, and a fixed phrase refers to a relatively long sentence. However, in the following explanation, both a fixed phrase and a phrase are described as “fixed sentence”. Shall be included.
JP2000-181972

  As described above, conventionally, in order to call a fixed sentence, a folder in which the fixed sentence is stored is opened, and a desired fixed sentence is selected from a large number of fixed sentences listed next. However, there are dozens of canned sentences, and there are hundreds of them depending on the case, so if you can't display them all at once, you have to scroll and it takes time and effort. Further, when folders are divided into hierarchies according to the attributes of fixed phrases so that they can be easily searched later, it is necessary to open the folders by following the hierarchies. In some cases, a desired fixed phrase cannot be found in the opened folder. In that case, it is necessary to reopen the folder and search again, which is troublesome.

The present invention is a medical information input device that includes an input unit, a display unit, and a storage unit, and inputs and registers patient medical information, and stores the medical information of the patient and is stored in the storage unit A template text that includes storage means, template information storage means that holds information on a template that is an input frame for inputting medical information by item, and is stored in the storage means, and at least a template sentence data and a template sentence code Boilerplate information storage means stored in the storage means, and boilerplate data arbitrarily set by the user, and boilerplate code arbitrarily set by the user to call the boilerplate data, registration means for registering said template text information storage means, display for displaying medical information input screen having a display area for displaying the template on the display means Control means; code input means for inputting a fixed sentence code in the input frame; and search means for searching the fixed sentence information storage means and reading fixed sentence information in response to the input of the fixed sentence code, the display The control means further controls the display of the corresponding fixed sentence after erasing the fixed sentence code in the input frame where the fixed sentence code is input based on the fixed sentence information read by the search means, Further, the present invention is provided with a storage control means for storing and controlling the displayed fixed sentence in the medical care information storage means in response to an instruction.

  According to the medical care information input device of the present invention, it is possible to directly call up and display a fixed sentence to be called by inputting a code of the fixed sentence into the input frame. For this reason, if you use a code that is easy to remember and use, you can call it more easily. Then, use the mouse to open folders divided into categories, and think about which category they belong to, such as searching for and specifying the desired one from the fixed phrase group, and mistakenly specify the category folder. It eliminates the hassle of opening and reopening, and the trouble of searching for the desired one out of many fixed sentences.

  FIG. 1 shows a block configuration of the medical information input device 10 according to the embodiment of the present invention. In the figure, 4 is a display device as information display means constituted by an LCD or the like, 5 is a keyboard as data input means, 6 is a pointing device such as a mouse, 1 is a CPU 2 as control means, and a memory 3 such as ROM and RAM. And 7 is a file device composed of storage means such as a hard disk device. The file device 7 stores a category file 11, a template file 12, a fixed sentence file 13, a master file 14, a patient file 15, and a medical treatment information file 16.

  The file device functions as fixed sentence information storage means and medical information storage means. The control device 1 has a function of receiving input from the keyboard 5 and the pointing device 6, a function of controlling the display of the display device 4, and a function of controlling the entire device 10. The keyboard 5 and the pointing device 6 function as input means in the following description. The medical information input device 10 may be a basic computer such as a general computer such as a personal computer. Then, a program having a function specific to this apparatus may be installed in the ROM or the file apparatus 7 in advance, or may be supplied by being stored in a storage medium such as a CD-ROM. Or you may make it downloadable via a network. When the control device 1 introduces and executes the program, functions unique to the present device are exhibited.

  FIG. 7 is a display example of a progress input screen 40 for inputting medical data in the present embodiment. This screen is a state in which the doctor further calls and displays each template in order to input the main complaint history, past history, body temperature and pulse data. Reference numeral 41 denotes a conventional tree view for selecting a fixed sentence stored by category, and reference numeral 42 denotes a template display area for displaying a template.

  Returning to FIG. 1, the category file 11 stored in the file device 7 is a file that defines a folder for storing fixed phrases. In this embodiment, the fixed phrases are divided into some categories, and folders are provided for each category to store the fixed phrases. This category or folder can be arbitrarily set by the user. As shown in FIG. 2, the category file 11 is composed of records such as a category ID, a category name, and private information. Among these, “category ID” is a unique ID assigned by the apparatus for each category. “Category name” is the name of the folder to be displayed on the left side of the tree view 41 shown in FIG. 7, and is arbitrarily set by the user. Specifically, it includes “main complaint / current medical history”, “basic medical information”, “findings”, and the like. The template file 12 is a file that stores information related to individual templates, which is an input frame for inputting medical care information item by item.

  The fixed phrase file 13 is a file for defining individual fixed phrases, and its record structure is shown in FIG. “Category ID” is a copy of the category ID shown in FIG. 2 and indicates to which category the fixed sentence belongs. That is, it is defined in which folder this fixed sentence is stored. The “standard text name” is a so-called title of the standard text displayed on the right side of the tree view 41 and can be arbitrarily set by the user. Since the display area is narrow, this title is displayed instead of the fixed phrase itself.

  The “fixed sentence code” is unique to the present application, and is a code that the user inputs in the frame of the template when calling each fixed phrase directly. The “standard text data” is the standard text to be input itself, that is, the registered standard text or phrase data, and is text data composed of letters and numbers.

  The master file 14 includes the names of all injuries and diseases that may be used in this medical institution, items such as medical treatments such as treatments and tests, drugs and prescriptions, and main complaints, findings, and vitals that are recorded in the medical record. It is a file registered in advance with each name and unique code. The patient file 15 is a file that stores patient-specific information such as a patient's name and address, and insurance information. The medical care information file 16 is a file that stores information related to medical care such as treatments, prescriptions, examinations, and patient's disease names performed on the patients. The patient file 15 and the medical information file 16 are associated with each other by a unique patient ID.

  Next, the operation of this embodiment will be described. The user registers in advance a fixed sentence that he / she wants to call directly with the fixed sentence code. Therefore, an appropriate folder, that is, a category is selected in the tree view, and a new registration of a fixed phrase is instructed. FIG. 6 is a display example of a fixed phrase creation screen 60 for the user to create a new fixed phrase that is controlled to be displayed on the display device 4 by the control device 1 in accordance with this instruction. Here, the fixed phrase name 61 is a name of a fixed phrase displayed in a list on the right side when a folder for each category is opened in the tree view 41, and is set by the user by inputting an arbitrary character string. The next fixed sentence 62 is a frame for inputting the fixed sentence data itself, and any text data can be used regardless of alphanumeric characters, kana-kanji, full-width or half-width. The fixed sentence code 63 is a code used when the user directly calls the fixed sentence using the code instead of via the tree view 41. In this embodiment, half-width katakana and numbers can be used and can be set arbitrarily by the user. However, unlike the above-described fixed phrase name 61, the fixed phrase codes must be unique. In the example shown in the figure, “Nod 2” is designated by half-width kana. The user can set the code freely as long as it does not collide with other fixed-form code, so it is only necessary to set a code that is easy to remember and easy to use.

  In response to the user instructing the OK button, the control device 1 sets the fixed sentence name, the fixed sentence, and the fixed sentence name in the fixed sentence file 13 in response to the user specifying the OK button. Storage control is performed for each record of the fixed phrase code. FIG. 4 shows an example of specific registration contents of a fixed sentence corresponding to the fixed sentence code.

  A procedure for a user to call and use a fixed phrase created and registered as described above will be described with reference to a flowchart of FIG. 5 and display examples of FIGS.

  For example, when the user gives an instruction to start inputting data such as progress from the chart No. 2 paper screen 80 shown in FIG. 11 in order to input data such as the patient's progress, the controller 1 inputs the progress etc. shown in FIG. Display control of the screen 40 is performed on the display device. Further, based on the information in the template file 12, display control of the main complaint history template 43, a past history template 44, a body temperature 45 and a pulse 46 template is controlled.

  Therefore, the user shifts the focus to the template to be input and inputs a fixed phrase code for calling a desired fixed phrase from the keyboard 5. At that time, when calling a plurality of types of fixed phrases at a time, input the fixed phrase codes by connecting them with delimiters. Also, when it is desired to repeatedly display the same fixed phrase as two or three, enter the fixed phrase code followed by a repetition symbol that specifies the number of repetitions. In this embodiment, the delimiter is a single-byte or full-width space character. The repetition symbol is composed of a combination of a number indicating the number of repetitions and an asterisk of a separation symbol indicating the boundary between the codes, and is a portion of “* 2” in the example described later. However, if you enter the template frame as it is, it will be treated as a normal character string, so it is decided to add a half-width pound sign “#” at the beginning and end of the code to indicate that it is a fixed phrase code. Yes.

  Here, for example, when the fixed sentence that the user wants to input is related to the main complaint history, first, the focus is reflected on the main complaint history template. That is, the cursor is displayed in the input frame of the main complaint history. Next, a desired fixed phrase code is input. When the code of the fixed sentence to be called is previously registered in the fixed sentence file 13 with “Nod 2” and “Suso 1”, for example, “#Suso 1 Node 1 *” is displayed in the input box as shown in FIG. Enter “2 #” in half-width kana and numbers. Then, a return key (enter key) or a tab key is pressed.

  In response to this, the control device 1 captures a series of character strings input in the input frame into the memory 3, and determines whether it is input as a normal character string or a fixed sentence code (step S1). . If there is a pound sign before and after the character string, the fixed phrase code is input. Therefore, after removing the preceding and following pound signs (S2), the remaining character string is searched for a delimiter and the character string is divided (step S3). ), Storing each divided character string in an array (S4), and then separating each character string stored in the array from a fixed sentence code based on the separator and cutting it (S5). A number is extracted from the repetition symbol (S6), and the number is stored in the number array (S7). That is, the character string input to the input box in the process so far is divided into individual fixed sentence codes, and further, the number-specified number is separated from the repetition symbol added to the end of each code.

  Then, the fixed phrase codes are read in the order stored in the array, the fixed phrase information corresponding to the fixed phrase codes is retrieved from the fixed phrase file 13 and read out, and displayed in the input frame (S8). At this time, the control device 1 functions as search means and display control means for reading out fixed sentence information. At that time, the fixed sentence is repeatedly displayed by the number stored in the number array (S9).

  FIG. 9 shows the screen on which the control apparatus 1 displays the fixed sentence in accordance with the input contents of the fixed sentence code shown in FIG. 8, that is, “#Shoo 1 Node 1 * 2 #”, through the above procedure. Show. The sentence that the fixed sentences are connected in the order of the fixed sentence codes specified in the input frame is displayed as “Chills, with a headache. My throat hurts from this morning. My throat hurts from this morning.”

  Therefore, the user can further edit the fixed sentence called in the input frame as necessary, as in the case of the character string input from the keyboard as usual. FIG. 10 shows a state where one of the fixed phrases “Nod 1” displayed repeatedly is edited and used as “the throat is swollen red from this morning”.

  When the fixed sentence is input and edited as described above, and the other medical data is input, and the OK button on the lower right is instructed, the control device 1 correspondingly inputs the input data to the medical information file. 16 and the display control so that these data are reflected on the chart No. 2 paper screen 80 and displayed. That is, at this time, the control device 1 functions as a storage control unit and a display control unit.

  As described above, in the present embodiment, since the code of the fixed sentence to be called can be directly input to the input target template and called, the folder divided by category is opened using the mouse as in the conventional method, Rather than searching for and specifying a desired item from the fixed phrase list, it can be called and displayed easily and quickly.

It is a block diagram which shows the structure of the medical treatment information input device of embodiment. It is a figure which shows the record structure of the category file of embodiment. It is a figure which shows the record structure of the fixed phrase file of embodiment. It is a figure which shows the specific registration example of a fixed phrase file. It is a flowchart which shows operation | movement of embodiment. It is a figure which shows the example of a display of the fixed form creation screen of embodiment. It is a figure which shows the example of a display of data input screens, such as progress of embodiment. It is a figure which shows the input example of the fixed phrase code in embodiment. It is a figure which shows the example of a display of the fixed sentence called in embodiment. It is a figure which shows the example of edit of the fixed phrase in embodiment. It is a figure which shows the example of a display of a medical chart 2 paper screen.

Explanation of symbols

DESCRIPTION OF SYMBOLS 1 Control apparatus 4 Display apparatus 5 Keyboard 6 Pointing device 7 File apparatus 11 Category file 12 Template file 13 Fixed sentence file 14 Master file 15 Patient file 16 Medical treatment information file

Claims (2)

A medical information input device comprising an input means, a display means, and a storage means for inputting and registering patient medical information,
Medical information storage means for holding patient medical information and stored in the storage means;
Template information storage means for holding information on a template which is an input frame for inputting medical care information by item and stored in the storage means;
A fixed sentence information storage unit that holds information related to a fixed sentence composed of at least fixed phrase data and a fixed sentence code and is stored in the storage unit;
Registration means for registering at least the fixed sentence data arbitrarily set by the user and the fixed sentence code arbitrarily set by the user to call the fixed sentence data in the fixed sentence information storage means;
Display control means for displaying on the display means a medical information input screen having a display area for displaying the template;
List display selection means for displaying a list of fixed sentences stored in the fixed sentence information storage means on the medical care information input screen and receiving selection input by a user, and controlling display of the selected fixed sentence in the input frame;
Code input means for inputting a fixed sentence code in the input frame;
Search means for searching the fixed sentence information storage means and reading fixed sentence information according to the input of the fixed sentence code,
The display control means further controls the display of the corresponding fixed sentence after erasing the fixed sentence code in the input frame where the fixed sentence code is input based on the fixed sentence information read by the search means. And storage control means for storing and controlling the displayed fixed sentence in the medical information storage means according to an instruction,
Medical information input device. The medical information input device according to claim 1,
The code input means allows a fixed sentence code to be added with a repetition symbol designating the number of repetitions, wherein the repetition symbol includes a number indicating the number of repetitions, a number and a fixed sentence code. The retrieval means separates the fixed phrase code input in the input box into a code and a repetition symbol, and sets the fixed sentence information for the separated code.
Searching and reading, and the display control means repeatedly controls the display of the fixed sentence as many times as specified by the separated repetition symbol based on the fixed sentence information read by the search means. .

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