JP6167648B2 - Document creation support program, method and apparatus - Google Patents

Description

  The present invention relates to a document creation support program, method, and apparatus.

  In medical institutions, a wide variety of documents such as letters of introduction and reports to be submitted to other medical institutions are frequently created.

  When a doctor creates a document such as a letter of introduction, it is necessary to find the necessary information from past medical records. However, it takes time and effort to find the necessary information from the charts that increase daily. The workload for creating documents is large.

  Conventionally, when extraction conditions such as a document name to be created (for example, a letter of introduction), a recipient, a target patient, and a disease name are selected by a doctor, medical information specified by the selected extraction condition is extracted, A technique for outputting a document in which medical information is written is known (see Patent Document 1).

JP 2002-207823 A

  However, even if the technique of Patent Document 1 is used, it is necessary to prepare a fine extraction condition for each document, which is troublesome.

  In one aspect, an object of the present invention is to provide a document creation support program, method, and apparatus capable of supporting creation of a document including a plurality of items.

In one aspect, the document creation support program is a document creation support program for supporting creation of a document related to the first patient including a plurality of items, and is an electronic medical record of a second patient different from the first patient. When an instruction for associating a word or phrase included in data with any of the plurality of items is received, the word or phrase is associated with the item and the second patient, and a document relating to the first patient is created When any of the plurality of items is selected, a predetermined range including the word or phrase associated with the selected item and a patient different from the first patient is set as the electronic chart of the first patient. It is a program that causes a computer to execute processing that is extracted from data and output.

In one aspect, the document creation support method is a document creation support method for supporting creation of a document related to a first patient including a plurality of items, and is an electronic medical record of a second patient different from the first patient. When a word or phrase contained in the data receiving an instruction to associate the one of the plurality of items, associated with the word or phrase in the second patient with said item, when creating the first document about the patient When any one of the plurality of items is selected, a predetermined range including the selected word and the word or phrase associated with a patient different from the first patient is set in the electronic medical record of the first patient. This is a document creation support method in which a computer executes a process of extracting and outputting from data.

In one aspect, the document creation support device is a document creation support device that supports creation of a document related to a first patient including a plurality of items, and is an electronic medical record of a second patient different from the first patient. When an instruction for associating a word or phrase included in the data with any of the plurality of items is received, an association unit that associates the item with the second patient and the word or phrase, and a document relating to the first patient In creating, when any of the plurality of items is selected, a predetermined range including the word or phrase associated with the selected item and a patient different from the first patient is set in the first patient. An output unit that extracts and outputs the electronic medical record data.

  Creation of a document including a plurality of items can be supported.

It is a figure showing roughly the composition of the medical information processing system concerning one embodiment. FIG. 2A is a diagram illustrating a hardware configuration of the server, and FIG. 2B is a diagram illustrating a hardware configuration of the doctor terminal. It is a functional block diagram of a server and a doctor terminal. It is a figure which shows an example of the data structure of an item master. It is a figure which shows an example of a treatment information provision document (introduction letter). It is a figure which shows an example of the data structure of an electronic medical chart table. It is a figure which shows an example of an electronic medical record input screen. FIG. 8A is a diagram showing an example of the data structure of the character type definition master, FIG. 8B is a diagram showing an example of the data structure of the document item association table, and FIG. It is a figure which shows an example of the data structure of a document item correlation disassembly table. It is a flowchart which shows the process of a registration process part. It is a flowchart which shows the specific process of step S20 of FIG. It is a flowchart which shows the selection assistance process performed in parallel with FIG. It is a flowchart which shows the process of an information provision part. FIGS. 13A and 13B are diagrams (part 1) for explaining the processing of FIGS. FIG. 14A and FIG. 14B are diagrams (part 2) for explaining the processing of FIG. 9 and FIG. FIG. 15A and FIG. 15B are diagrams (part 1) for explaining the processing of FIG. FIGS. 16A and 16B are diagrams (part 2) for explaining the processing of FIG. FIG. 17A is a diagram showing an example of the data structure of the document item association table after the processing of FIG. 11 is performed, and FIG. 17B is the document item association after the processing of FIG. It is a figure which shows an example of the data structure of a decomposition | disassembly table. FIG. 18A is a diagram for explaining the processing in step S70 in FIG. 12, and FIG. 18B is a diagram for explaining the processing in step S96 in FIG. It is a figure which shows an example of the process result of FIG. 12 in the case of creating the patient's introduction letter.

  Hereinafter, an embodiment of a medical information processing system will be described in detail with reference to FIGS. FIG. 1 schematically shows a configuration of a medical information processing system 100 according to an embodiment. The medical information processing system 100 according to the present embodiment is a system that performs data management of electronic medical records created by a doctor and supports creation of a document (for example, a medical information provision form (introduction letter)) by the doctor.

  As shown in FIG. 1, the medical information processing system 100 includes a server 10 as a document creation support apparatus and a plurality of doctor terminals 20. The server 10 and the doctor terminal 20 are connected to a network 80 such as the Internet or a LAN (Local Area Network).

  FIG. 2A shows the hardware configuration of the server 10. As shown in FIG. 2A, the server 10 includes a CPU (Central Processing Unit) 90, a ROM (Read Only Memory) 92, a RAM (Random Access Memory) 94, and a storage unit (here, an HDD (Hard Disk Drive)). 96, a network interface 97, a portable storage medium drive 99, and the like. Each component of the server 10 is connected to a bus 98. In the server 10, a program (including a document creation support program) stored in the ROM 92 or the HDD 96 or a program (including a document creation support program) read by the portable storage medium drive 99 from the portable storage medium 91 is stored in the CPU 90. As a result, the functions of the screen providing / information managing unit 12, the registration processing unit 14 as the association unit and the information output unit, and the information providing unit 16 as the output unit shown in FIG. 3 are realized. 3 also shows an item master 31, an electronic medical record table 32, a character type definition master 33, a document item association table 34, and a document item association decomposition table 35 stored in the HDD 96 of the server 10. . The specific data structure of each master 31, 33 and table 32, 34, 35 will be described later.

  The screen providing / information management unit 12 provides the doctor terminal 20 with an input screen for an electronic medical record and an input screen for a document (for example, a letter of introduction) other than the electronic medical record in response to a request from the doctor terminal 20. . The screen provision / information management unit 12 manages information input on each screen. The registration processing unit 14 converts a sentence input to the electronic medical record or a word or phrase included in the sentence according to an operation by the user (doctor) on the doctor terminal 20 into a predetermined item of a document other than the electronic medical record. Are registered in the document item association table 34 and the document item association decomposition table 35. The information providing unit 16 provides information for reducing the burden on the user (doctor) when a document other than the electronic medical record is created on the doctor terminal 20.

  FIG. 2B shows the hardware configuration of the doctor terminal 20. The doctor terminal 20 is a terminal for a doctor to browse an electronic medical record and other documents and input information. As shown in FIG. 2B, the doctor terminal 20 includes a CPU 190, a ROM 192, a RAM 194, a storage unit (HDD) 196, a display 193, an input unit 195, a network interface 197, a portable storage medium drive 199, and the like. I have. Each component of the doctor terminal 20 is connected to the bus 198. The display 193 includes a liquid crystal display and the input unit 195 includes a keyboard, a mouse, a touch panel, and the like. In the doctor terminal 20, the CPU 190 executes a program stored in the ROM 192 or the HDD 196 or a program read by the portable storage medium drive 199 from the portable storage medium 191, whereby the display process shown in FIG. 3 is performed. Functions as the unit 60 and the input processing unit 62 are realized.

  The display processing unit 60 displays various screens on the display 193 in response to instructions from the units 12, 14, and 16 of the server 10. The input processing unit 62 receives information input by the user (doctor) using the doctor terminal 20 via the input unit 195 and transmits the information to the units 12, 14, and 16 of the server 10.

  Here, each master and table which the server 10 has will be described.

  FIG. 4 shows an example of the data structure of the item master 31. The item master 31 is a master that stores items of documents (such as letters of introduction) other than electronic medical records. As shown in FIG. 4, the item master 31 has fields of “document name”, “item number”, and “item”. For example, an item (item) included in an introduction letter as shown in FIG. 1 to item 7) and other document items are stored. The referral letter is a document issued when a patient is transferred to another medical institution (for example, a university hospital). Specifically, the referral letter summarizes various medical information such as the transition of the medical condition at the original medical institution, medication, treatment, test results, etc. so that the doctor in charge of the referral medical institution can grasp in a short time. It is a document.

  FIG. 6 shows an example of the data structure of the electronic medical record table 32. The electronic medical record table 32 is a table that is created for each doctor and stores information input by the doctor on the electronic medical record input screen as shown in FIG. Specifically, the electronic medical record table 32 includes “identification number”, “patient name”, “medical record date”, “serial number”, “free”, “main complaint”, “S”, “O”, “A”. , “P”, and “treatment / prescription” fields. The “identification number” field stores the patient identification number, and the “patient name” field stores the patient name information. The date of information input is stored in the “medical record date” field, and the serial number of the medical chart created for each disease of the patient is stored in the “serial number” field. Note that the date of data having the same serial number and the largest serial number means a “disease name end date” to be described later. In the “free” field, the information entered in the “free” column of the electronic medical record input screen of FIG. 7 is stored, and in the “main complaint” field, the “main complaint” column of the electronic medical record input screen of FIG. The input information is stored. The doctor enters the main complaint that triggered the patient's visit, such as chest pain and fever, in the “main complaint” column. In the fields “S”, “O”, “A”, and “P”, the information entered in the “S”, “O”, “A”, and “P” fields of the electronic medical record input screen of FIG. Stored. The doctor inputs the patient's complaint and medical history as subjective data in the S (Subject) field, and enters the examination findings and examination findings as objective data in the O (Object) field. In addition, the doctor inputs an evaluation of information in the S and O columns in the A (Assessment) column, and inputs a treatment policy based on the information in the SOA column in the P (Plan) column. In the “treatment / prescription” field, information input in the “treatment / prescription” field of the electronic medical record input screen of FIG. 7 is stored. In addition, the doctor inputs the specific contents of the actually performed treatment or prescription in the treatment / prescription column.

  FIG. 8A shows an example of the data structure of the character type definition master 33. In the character type definition master 33, “character type” corresponding to “JIS code” is defined.

  FIG. 8B shows an example of the data structure of the document item association table 34. The document item association table 34 is a table for storing a sentence input by the doctor on the screen of the electronic medical record in association with an item of a certain document. The specific data structure of the document item association table 34 will be described later.

  FIG. 8C shows an example of the data structure of the document item association decomposition table 35. The document item association decomposition table 35 is a table that stores words or phrases included in the sentences stored in the document item association table 34 as decomposition data. A specific data structure of the document item association decomposition table 35 will be described later.

  Next, the processing of the server 10 will be described in detail along the flowcharts of FIGS. 9 to 12 with appropriate reference to other drawings.

(Processing of registration processing unit 14)
First, the processing of the registration processing unit 14 will be described with reference to the flowcharts of FIGS.

  The process of FIG. 9 is for registering in advance a sentence that is likely to be used when creating a document such as a letter of introduction when a doctor inputs information on the electronic medical record input screen (FIG. 7). It is processing of. The processing of FIG. 9 is started from the stage where an electronic medical record input screen as shown in FIG. 7 is displayed on the display 193 of the doctor terminal 20. Note that it is assumed that the doctor has entered the information of the patient “Patient Taro” on the electronic medical record input screen of FIG. 7 on “February 1, 2012”.

  In the process of FIG. 9, first, in step S <b> 10, the registration processing unit 14 waits until the chart input content range is selected and right-clicked at the selected location. For example, it is assumed that the doctor inputs “I caught a cold. There is a possibility of influenza” on the electronic medical record input screen as shown in FIG. Then, as shown in FIG. 13B, the doctor selects an input content range using an input unit 195 (for example, a mouse) and then right-clicks on the selected portion. At this stage, the registration processing unit 14 proceeds to step S12. In step S10, instead of the right click operation, for example, it is possible to wait until a specific key on the keyboard is pressed.

  In step S12, the registration processing unit 14 acquires a document item from the item master 31 (FIG. 4). Next, in step S <b> 14, the registration processing unit 14 transmits data on the document item association menu screen to the display processing unit 60 of the doctor terminal 20. Then, the display processing unit 60 displays a document item association menu screen 51 on the display 193 as shown in FIG.

  Next, in step S16, the registration processing unit 14 determines whether or not a document item has been designated. If the determination is negative, the process proceeds to step S18, and the registration processing unit 14 determines whether or not a cancel operation has been performed. Here, the canceling operation is, for example, an operation of placing the mouse pointer outside the document item association menu screen 51 and left-clicking or pressing a specific button (for example, “esc” button) on the keyboard. If the determination in step S18 is affirmed, the entire process of FIG. 9 is terminated. If the determination in step S18 is negative, the process returns to step S16.

  On the other hand, if the determination in step S16 is affirmed while the determinations in steps S16 and S18 are repeated, the process proceeds to step S20. Here, as shown in FIG. 14B, it is assumed that the doctor designates the item “symptom progress and test result” of the item number “4” of the introduction letter on the document item association menu screen 51. .

  In step S20, the registration processing unit 14 executes a registration processing subroutine. The registration processing unit 14 executes processing according to the flowchart of FIG. 10 as the registration processing in step S20.

(Registration process (S20))
First, the registration processing unit 14 registers the contents of the selected portion in the document item association table 34 in step S30 of FIG. Specifically, as shown in FIG. 8B, the registration processing unit 14 sets “patient name” as “patient Taro”, “medical record date” as “2012/2/1”, and “document name”. , "Clinical information provision form (introduction letter)", "Item number" as "4", "Item" as "Symptom progress and test results", "Overall data" as "Cold cold. Possibility of influenza Yes. "Is stored.

  Next, in step S32, the registration processing unit 14 acquires the character code of the character next to the character investigated last time (first character in the first case) in the range of the selected location. Here, it is assumed that the registration processing unit 14 has acquired the character code of the first character “Wind” (JIS code = 4977).

  Next, in step S34, the registration processing unit 14 acquires a character type from the character code. Here, the registration processing unit 14 acquires “kanji” from the character type definition master 33. Next, in step S36, the registration processing unit 14 determines whether or not the character type of the character block being stored in the temporary storage area is the same. Here, since the character block is not yet stored in the temporary storage area, the determination is denied and the process proceeds to step S40.

  In step S40, the registration processing unit 14 determines whether the character block being stored does not exist in the document item association decomposition table 35. Here, since the character block is not yet stored in the temporary storage area, the determination is denied and the process proceeds to step S44. In step S44, the registration processing unit 14 discards the character block being stored, and stores the current character as a new character block. In this case, since there is no character block to be discarded, the character “wind” is stored as a new character block.

  Next, in step S46, the registration processing unit 14 determines whether or not the acquired character is the last character of the entire data. If the determination here is negative, the process returns to step S32.

  Returning to step S32, the registration processing unit 14 acquires the character code of the character next to the character investigated last time in the range of the selected portion. Here, it is assumed that the registration processing unit 14 has acquired the character code “JIS” of the second character (JIS code = 3C59).

  Next, in step S <b> 34, the registration processing unit 14 acquires the character type “Kanji” from the character code and the character type definition master 33. Next, in step S36, the registration processing unit 14 determines whether or not the character type of the character block being stored in the temporary storage area is the same. Here, since the acquired character type “kanji” and the character type “kanji” of the character block “wind” stored in the temporary storage area are the same, the determination in step S36 is affirmed and the process returns to step S38. Transition.

  In step S38, the registration processing unit 14 combines the current character with the stored character block. Specifically, the registration processing unit 14 sets the character block as “cold”. Thereafter, the determination in step S46 is denied, and the process returns to step S32.

  Returning to step S 32, the registration processing unit 14 acquires the character code (JIS code = 2472) of the next character “O”. In step S 34, the character type “Hiragana” of “O” is changed to the character type definition master 33. Get from. Next, in step S36, it is determined whether or not the acquired character type “Hiragana” is the same as the character type “Kanji” of the character block “cold” being stored in the temporary storage area. Then, the process proceeds to step S40.

  In step S <b> 40, the registration processing unit 14 determines whether the character block being stored (“cold”) does not exist in the document item association decomposition table 35. If the determination here is affirmative, the process proceeds to step S42, and the registration processing unit 14 registers the character block being stored (“cold”) in the document item association decomposition table 35 (FIG. 8C). reference). That is, in step S42, it can be said that the word or phrase is associated with the item in accordance with an instruction to associate the word or phrase included in the electronic medical record table 32 with the selected item.

  In step S <b> 42, the registration processing unit 14 does not register the character block in the document item association decomposition table 35 when the character type of the character block being stored is “Hiragana”. Thereafter, the process proceeds to step S44. On the other hand, if the determination in step S40 is negative, the process proceeds to step S44 without passing through step S42.

  In step S44, the registration processing unit 14 discards the character block being stored (“cold”) and stores the current character (“O”) as a new character block. Next, in step S46, the registration processing unit 14 determines whether or not it is the last character, and if the determination here is negative, the process returns to step S32.

  Thereafter, by repeating the above process, as shown in FIG. 8C, “cold”, “flu”, and “possibility” are registered as “decomposition data”. Then, if the determination in step S46 is affirmative, the entire process in FIG. 10 and the entire process in FIG. 9 are terminated. The punctuation marks may be handled as “Hiragana” or as “other characters” and may not be registered in the document item association decomposition table 35 as in the case of Hiragana.

  By performing the processing as described above, in the document item association table 34, the entire data “I caught a cold. There is a possibility of influenza” is associated with the item “Symptom progress and test results” of the referral letter. Become. Also. In the document item association decomposition table 35, the decomposition data “cold”, “influenza”, and “possibility” are associated with the item “symptom progress and test result” of the introduction letter. These registered data are data used when a doctor creates an introduction letter or used in a selection support process described later.

(Selection support processing)
Next, based on FIG. 11, the process for reducing the labor of the doctor in the process of FIG. 9 will be described. The process of FIG. 11 is a process performed in parallel with the process of FIG. Note that it is assumed that the doctor has input the information of the patient “Taro” on the electronic medical record input screen of FIG. 7 on “March 1, 2013”. That is, it is assumed that the document item association table 34 in FIG. 8B and the document item association decomposition table 35 in FIG. 8C have already been created.

  In the process of FIG. 11, first, in step S50, the registration processing unit 14 monitors and acquires the chart input character string. Next, in step S <b> 52, the registration processing unit 14 searches the document item association decomposition table 35 for the acquired characters. Next, in step S54, the registration processing unit 14 determines whether or not one or more pieces of decomposed data included in the document item association decomposition table 35 exist in the acquired characters. If the determination is negative, the process returns to step S50. If the determination is positive, the process proceeds to step S56. As shown in FIG. 15A, when the doctor inputs “cold”, the character “cold” exists as decomposed data in the document item association decomposition table 35 (FIG. 8C). Therefore, the determination in step S54 is affirmed.

  When the process proceeds to step S56, the registration processing unit 14 selects a sentence including the character string “cold” (see a rectangular frame in FIG. 15B). Next, in step S58, the registration processing unit 14 determines whether a line feed has been made. When judgment here is denied, it returns to step S56. Thereafter, the selection range is expanded until a line break is made. For example, as shown in FIG. 16A, if a line break occurs after “cold is severe”, the registration processing unit 14 The process proceeds to S60.

  In step S60, the registration processing unit 14 displays a document item association menu screen 52 as shown in FIG. 16A with the document item in which the character string “cold” is registered as a selection candidate.

  Next, in step S62, the registration processing unit 14 determines whether or not a document item has been designated. If the determination is negative, the process proceeds to step S64, and the registration processing unit 14 determines whether or not a cancel operation has been performed, as in step S18 of FIG. If the determination in step S64 is affirmed, the entire process of FIG. 11 is terminated. If the determination in step S64 is negative, the process returns to step S62.

  Thereafter, when the determination in step S62 is affirmative, that is, as shown in FIG. 16B, when the doctor selects the item “symptom progress and test result” of the introduction letter, the process proceeds to step S66. . In step S66, the registration processing unit 14 executes the registration process according to the flowchart of FIG. 10 as in step S20 described above. As a result, as shown in FIG. 17A, the document item association table 34 is registered with “cold and severe cough” as shown in FIG. 17A, and the document item association table 35 shows FIG. 17B. As shown in FIG. 5, “cough” is registered as the decomposition data (“cold” is already registered as decomposition data, and is not registered this time).

  In this way, by performing the processing of FIG. 11, the doctor can select the document item association table 34 or the document item without performing an operation of selecting and registering a sentence as shown in FIG. 13B. Data can be easily registered in the association decomposition table 35.

(Document creation support processing)
Next, a process performed by the information providing unit 16 when the doctor creates a document other than the electronic medical record will be described with reference to the flowchart of FIG. In the process of FIG. 12, in response to a request from the doctor terminal 20, the screen providing / information management unit 12 converts the screen data of a document other than the electronic medical record (here, referred to as an introduction letter) to the doctor terminal 20 Is started from the stage of transmission to the display processing unit 60 (that is, the stage of the introduction letter screen displayed on the display 193 of the doctor terminal 20). In the following, a case where the doctor creates an introduction letter for the patient name “patient Taro” on “March 1, 2013” will be described.

  In the process of FIG. 12, first, in step S <b> 70, the information providing unit 16 acquires a document item from the item master 31 based on the focused location. Here, as shown in FIG. 18A, it is assumed that the item “symptom progress and test result” of the introduction letter is focused (selected by the mouse).

  Next, in step S <b> 72, the information providing unit 16 acquires one piece of overall data of the patient (patient Taro) registered in the item from the document item association table 34. Here, it is assumed from FIG. 17A that “a cold has been caught. The possibility of influenza” has been acquired.

  Next, in step S <b> 74, the information providing unit 16 acquires from the electronic medical record table 32 the last (most recent) medical record date (that is, the disease name end date) of the same disease name as the medical record in which the acquired entire data is input. Here, it is assumed that “2012/2/1” is acquired as the end date of the disease name of the entire data “I caught a cold. There is a possibility of influenza”.

  In step S76, the information providing unit 16 determines whether or not disease name end date> document creation date-3 months. That is, it is determined whether the disease name end date is three months or more before the document creation date. Here, since the disease name end date is three months or more before the document creation date, the determination in step S76 is denied and the process proceeds to step S80. In step S80, the information providing unit 16 determines whether or not all of the entire data has been acquired. Here, however, the determination is negative because the entire data “cold is severely coughed” has not been acquired yet. Then, the process proceeds to step S72.

  Thereafter, in step S72, the information providing unit 16 acquires the entire data “Cold is severe due to a cold.” In step S74, the information providing unit 16 acquires the disease name end date “2013/3/1”. In step S76, since the disease name end date and the document creation date are the same day, the determination is affirmed, and the information providing unit 16 proceeds to step S78.

  When the process proceeds to step S78, the information providing unit 16 adds the entire data “Cold is severe due to a cold” as a selection candidate. If the determination in step S80 is affirmative, the process proceeds to step S82.

  In step S82, the information providing unit 16 obtains from the document item association decomposition table 35 decomposition data of other patients registered in association with the item (here, the item “symptom progress and examination result” of the introduction letter). To do. That is, the information providing unit 16 acquires any one (for example, “throat”) of decomposition data of other patients associated with the item “symptom progress and test result” of the referral letter. Next, in step S <b> 84, the information providing unit 16 searches the electronic medical record table 32 for a portion corresponding to the decomposed data “throat” from the medical record input content (input content related to the patient “patient Taro”). That is, in step S84, the information providing unit 16 extracts a predetermined range (sentence) including a word or phrase associated with the selected item from the electronic medical record table 32 in response to the item selection of the document by the doctor. It can be said that.

  Next, in step S86, the information providing unit 16 determines whether there is a corresponding part. If the determination is negative, that is, if there is no sentence including the character “throat” in the patient Taro's electronic medical record table 32, the process proceeds to step S94. When the process proceeds to step S94, the information providing unit 16 determines whether or not all pieces of decomposed data have been searched. If the determination here is negative, the process returns to step S84, and new decomposed data is obtained. Perform a search for.

  On the other hand, if the determination in step S86 is affirmative, the process proceeds to step S88. In step S88, the last (most recent) chart date (that is, the disease name end date) of the same disease name as the chart including the decomposition data is acquired from the electronic chart table 32. Next, in step S90, the same determination as in step S76 is executed. If the determination in step S90 is negative, that is, if the disease name end date is three months or older than the document creation date, the process proceeds to step S94. On the other hand, if the determination in step S90 is affirmative, that is, if the disease name end date is not three months or older than the document creation date, the process proceeds to step S92.

  In step S92, the information providing unit 16 adds a sentence from a line feed code to a line feed code including the relevant part to the selection candidate. Thereafter, the process proceeds to step S94.

  If the determination in step S94 is affirmative, the process proceeds to step S96. When the process proceeds to step S96, the information providing unit 16 displays selection candidates. More specifically, the information providing unit 16 transmits selection candidate screen data to the display processing unit 60. The display processing unit 60 displays the selection candidates on the display 193 when the data is received. In the present embodiment, the whole data “Cold is bad due to a cold” is selected as a selection candidate in steps S70 to S80 in FIG. 12, whereas no sentence is added to the selection candidate in steps S82 to S94. Shall. In this case, as shown in FIG. 18B, only the whole data “Cold is severe due to a cold” is displayed.

  Next, in step S98, the information providing unit 16 determines whether the selection candidate has been selected by the doctor. If the determination here is negative, in step S100, the information providing unit 16 determines whether or not a cancel operation has been performed. If the determination here is affirmed, the entire process of FIG. 12 is terminated. On the other hand, if the determination in step S100 is negative, the process returns to step S98. Then, when the determinations in steps S98 and S100 are repeated and the determination in step S98 is affirmative, that is, when the doctor selects the entire data “cold and cough is severe.” The providing unit 16 performs input processing. That is, the information providing unit 16 inputs the selected whole data “severe cough due to cold” in the item “symptom progress and test result” field of the introduction letter, and finishes the entire process of FIG. The doctor may use the input whole data “Cough is severe due to a cold” as it is in the introduction letter, or may be corrected as appropriate.

  Next, a case where the doctor creates an introduction letter for the patient “Patient Saburo” included in the electronic medical record table 32 of FIG. 6 will be described. Here, it is assumed that no data of “Patient Saburo” exists in the document item association table 34 or the document item association decomposition table 35. In this case, since the entire data is not acquired in step S72, the processing / judgment in steps S74 to S80 is omitted, and the process proceeds to step S82. And the process after step S82 will be performed.

  For example, when the item “symptom progress and test result” of the referral letter of “patient Saburo” is focused, in step S82, the information providing unit 16 acquires, for example, the decomposition data “cough”. In step S <b> 84, the information providing unit 16 searches for the decomposed data “cough” in the electronic medical record table of “Patient Saburo”. As a result of the processing / judgment in steps S86 to S92, in step S96, as shown in FIG. 19, the sentence “Disease of cough faster than yesterday” with the disease name end date “2013/1/1” is displayed as a selection candidate. Will be.

  As described above, by executing the processing of FIG. 12, the doctor creates a referral letter without creating necessary information from past medical records when creating a document such as a referral letter. Sentences related to the patient's medical condition can be displayed as selection candidates. Then, the doctor can input a sentence related to the patient's medical condition by selecting from the selection candidates.

  As described above in detail, according to the present embodiment, when the registration processing unit 14 receives an instruction to associate a word or phrase included in the electronic medical record data with one of the items of the document (S16: Yes, S62: (Yes), a word or phrase is associated with the item in the document item association decomposition table 35 (S42), and the information providing unit 16 selects one of a plurality of items when creating a document. A sentence including a word or phrase associated with the item is extracted from the electronic medical record data (S92) and output (S96). As a result, when creating a document such as a letter of introduction, the doctor selects a document item (without introducing a letter of introduction) without searching for necessary information from past medical records. By simply selecting an appropriate sentence from the sentence relating to the patient's medical condition to be created, it is possible to input the document. Thus, according to the server 10 of the present embodiment, it is possible to support creation of a document having a plurality of items by a doctor.

  In the present embodiment, the registration processing unit 14 associates a sentence including a word or phrase with an item in the document item association table 34 (S32). And the information provision part 16 outputs this sentence, when the sentence containing a word or a phrase is matched with the selected item (S78, S96). In this way, it is possible to simplify the process by outputting a sentence previously associated with the doctor. In addition, the doctor can freely determine a sentence to be output for each item of the document.

  In the present embodiment, when the doctor creates an electronic medical record, when the same word or phrase as the word or phrase associated with a certain item is input, the registration processing unit 14 displays the word or phrase. Information (document item association menu screen 52) for inputting an instruction for associating an included sentence (from line feed code to line feed code) with an item is output (FIG. 11). Thus, the doctor can easily register data in the document item association table 34 and the document item association decomposition table 35 without performing an operation such as selecting a sentence and right-clicking.

  In this embodiment, in step S76 or step S90, the information providing unit 16 determines whether or not to select the entire data or the retrieved sentence as a selection candidate based on the relationship between the disease name end date and the document creation date. Deciding. Thereby, it is possible to prevent an old sentence such as a sentence relating to a disease that is completely cured from being selected as a selection candidate. However, the present embodiment is not limited to this, and the determinations in steps S76 and S90 may be omitted.

  In the above embodiment, the case where the processes of FIGS. 9 and 11 are performed in parallel has been described. However, the present invention is not limited to this, and only the process of FIG. 9 may be performed.

  In the above embodiment, the document item association table 34 is prepared and the entire data is stored. However, the present invention is not limited to this. For example, only the document item association decomposition table 35 may be prepared and only the decomposition data may be stored. In this case, in the process of FIG. 12, the processes of steps S70 to S80 may be omitted.

  In the above embodiment, the case where the document created by the doctor is an introduction letter has been described. However, the document is not limited to this, and may be a document such as a visiting nursing instruction.

  Each doctor terminal 20 may have the function of the server 10 described in the above embodiment. In this case, the function of each part 12, 14, and 16 of the server 10 shown in FIG. 3 is implement | achieved by running a program in CPU190 of each doctor terminal 20. FIG.

  The above processing functions can be realized by a computer. In that case, a program describing the processing contents of the functions that the processing apparatus should have is provided. By executing the program on a computer, the above processing functions are realized on the computer. The program describing the processing contents can be recorded on a computer-readable recording medium (except for a carrier wave).

  When the program is distributed, for example, it is sold in the form of a portable recording medium such as a DVD (Digital Versatile Disc) or a CD-ROM (Compact Disc Read Only Memory) on which the program is recorded. It is also possible to store the program in a storage device of a server computer and transfer the program from the server computer to another computer via a network.

  The computer that executes the program stores, for example, the program recorded on the portable recording medium or the program transferred from the server computer in its own storage device. Then, the computer reads the program from its own storage device and executes processing according to the program. The computer can also read the program directly from the portable recording medium and execute processing according to the program. Further, each time the program is transferred from the server computer, the computer can sequentially execute processing according to the received program.

  The above-described embodiment is an example of a preferred embodiment of the present invention. However, the present invention is not limited to this, and various modifications can be made without departing from the scope of the present invention.

In addition, the following additional remarks are disclosed regarding description of the above embodiment.
(Supplementary note 1) A document creation support program for supporting creation of a document including a plurality of items,
When receiving an instruction to associate a word or phrase included in the electronic medical record data with any of the plurality of items, the word or phrase is associated with the item,
When creating the document, when any of the plurality of items is selected, a predetermined range including the word or phrase associated with the selected item is extracted from the electronic medical record data and output. A document creation support program that causes a computer to execute processing.
(Supplementary Note 2) In the process of associating, a sentence including the word or phrase is further associated with the item,
The document creation support program according to appendix 1, wherein in the output process, if the selected item is associated with a sentence including the word or phrase, the sentence is output.
(Supplementary Note 3) When creating an electronic medical record, if the same word or phrase as the word or phrase associated with the item is input, an instruction to associate a predetermined range including the word or phrase with the item The document creation support program according to appendix 1 or 2, further comprising: causing the computer to further execute a process of outputting information for causing the computer to input information.
(Appendix 4) A document creation support method for supporting creation of a document including a plurality of items,
When an instruction for associating a word or phrase included in the electronic medical record data with any of the plurality of items is received, the step of associating the word or phrase with the item;
When creating the document, when any of the plurality of items is selected, a predetermined range including the word or phrase associated with the selected item is extracted from the electronic medical record data and output. A document creation support method, characterized in that a computer executes the step of
(Supplementary Note 5) In the associating step, a sentence including the word or phrase is further associated with the item,
5. The document creation support method according to appendix 4, wherein, in the outputting step, if a sentence including the word or phrase is associated with the selected item, the sentence is output.
(Supplementary Note 6) When creating an electronic medical record, when a word or phrase that is the same as the word or phrase associated with the item is input, an instruction to associate a predetermined range including the word or phrase with the item 6. The document creation support method according to appendix 4 or 5, wherein the computer further executes a step of outputting information for inputting.
(Supplementary note 7) A document creation support apparatus for supporting creation of a document including a plurality of items,
When an instruction for associating a word or phrase included in the electronic medical record data with any of the plurality of items is received, an association unit that associates the word or phrase with the item;
When creating the document, when any of the plurality of items is selected, a predetermined range including the word or phrase associated with the selected item is extracted from the electronic medical record data and output. A document creation support apparatus.
(Supplementary Note 8) The association unit further associates a sentence including the word or phrase with the item,
The document creation support apparatus according to appendix 7, wherein the output unit outputs the sentence when the sentence including the word or the phrase is associated with the selected item.
(Supplementary Note 9) When the same word or phrase as the word or phrase associated with the item is input when creating the electronic medical record, an instruction to associate a predetermined range including the word or phrase with the item 9. The document creation support apparatus according to appendix 7 or 8, further comprising an information output unit that outputs information for inputting.

10 server (document creation support device)
14 Registration processing unit (association unit, information output unit)
16 Information provision section (output section)

Claims (5)

A document creation support program for supporting creation of a document related to a first patient including a plurality of items,
When an instruction to associate a word or phrase included in the electronic medical record data of the second patient different from the first patient with any of the plurality of items is received, the word or phrase is given to the item and the second patient. Map
When creating a document related to the first patient , if any of the plurality of items is selected, the selected item and the word or phrase associated with a patient different from the first patient are included. Extracting and outputting a predetermined range from the electronic medical record data of the first patient ,
A document creation support program that causes a computer to execute processing. In the association process, when an instruction to associate a word or phrase included in the electronic medical record data of the first patient with any of the plurality of items is received, the word or phrase is associated with the item and the first patient. And associating a predetermined range including the word or phrase,
2. The document creation support according to claim 1, wherein the output process further outputs a predetermined range including the selected item and the word or phrase associated with the first patient. program. When creating the electronic medical record, when a word or phrase that is the same as the word or phrase associated with the item is input, an instruction for associating the predetermined range including the word or phrase with the item is input. The document creation support program according to claim 2 , further causing the computer to execute a process of outputting information. A document creation support method for supporting creation of a document related to a first patient including a plurality of items,
When an instruction to associate a word or phrase included in the electronic medical record data of the second patient different from the first patient with any of the plurality of items is received, the word or phrase is given to the item and the second patient. the association,
When creating a document related to the first patient , if any of the plurality of items is selected, the selected item and the word or phrase associated with a patient different from the first patient are included. A predetermined range is extracted from the electronic medical record data of the first patient and output .
A document creation support method, wherein a computer executes processing . A document creation support apparatus for supporting creation of a document related to a first patient including a plurality of items,
When an instruction to associate a word or phrase included in the electronic medical record data of the second patient different from the first patient with any of the plurality of items is received, the word or phrase is given to the item and the second patient. An associating unit that associates
When creating a document related to the first patient , if any of the plurality of items is selected, the selected item and the word or phrase associated with a patient different from the first patient are included. An output unit that extracts and outputs a predetermined range from the electronic medical record data of the first patient .

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