JP6257953B2 - Electronic medical record creation device and electronic medical record creation system - Google Patents

Description

  Embodiments described herein relate generally to an electronic medical record creation apparatus and an electronic medical record creation system.

  In recent years, electronic medical records in which information on medical records of individual patients is digitized and stored in a database have become widespread. This electronic medical chart is created each time a person who creates the electronic medical chart examines a patient.

  However, not all entries in the electronic medical record are necessarily new. In that case, the same prescription may be input with reference to past prescriptions and treatments, test results, findings, and the like. Further, the amount of information entered (recorded) in the electronic medical record tends to increase, and the labor of the person who creates the electronic medical record increases.

  Therefore, in this case, for example, by transferring necessary contents, information is simply taken over and entered. Alternatively, there may be used a display indicating that the description content is the same when the input is repeated with the description content of the previous chart called “Do description (Do display)”.

  On the other hand, for example, if the Do is written about the prescription when the description content is enormous, sufficient confirmation by the person who creates the electronic medical record may be neglected. In order to eliminate such an adverse effect, for example, when Do display is applied, it is possible to easily check the content of the Do display by having a means for displaying the description content as a basis on the screen. (See Patent Document 1 below).

Japanese Patent Laid-Open No. 2000-200236

  However, the invention disclosed in Patent Document 1 does not give consideration to the following points.

  That is, all the description contents that are the basis are displayed, and the importance of the displayed contents is not considered. Therefore, particularly when there are many display objects, there is a possibility that it may be difficult to surely confirm the description contents that particularly require confirmation.

  The present invention has been made to solve the above problems, and the object of the present invention is to determine the priority of confirmation for each displayed item when Do display is made in the creation of an electronic medical record. An object of the present invention is to provide an electronic medical record creation device and an electronic medical record creation system capable of easily and reliably confirming Do display of items to be confirmed by displaying on the screen based on the priority.

Features of the first aspect of the present invention, in the electronic medical chart creating device, a storage unit for storing the contents of the entry to be that a repetitive formulation or order, and a display unit for displaying the contents of the entry, display An input section for inputting whether to repeatedly prescribe or order the contents of the entered entry, a risk level determining section for determining the risk level of each entry, and the risk determined by the risk level determining section A determination unit that determines the confirmation conditions based on the level, and a screen level display mode for confirming whether or not to repeatedly prescribe or order the items to be confirmed according to the confirmation conditions, and a risk level determination unit And a display mode determination unit that instructs the display unit to display a display mode according to the risk level determined for each confirmation item.

According to a twelfth aspect of the present invention, in the electronic medical record creation apparatus, a storage unit that stores the contents of the entry items of the medical order that is a target of repeated prescription or order, a display unit that displays the contents of the entry items, Determined by the input section for inputting whether to repeatedly prescribe or order the contents of the displayed entry, the risk level determination section for determining the risk level of each entry, and the risk level determination section A determination unit that determines the confirmation conditions based on the risk level, and a screen display mode for confirming whether or not to repeatedly prescribe or order the required confirmation items according to the confirmation conditions, as well as the required confirmation items and a display mode decision unit for instructing the display of the determined display mode to the display unit each time, determination unit, the table示態like based on the risk level It is determined as one of the confirmation conditions the display frequency.

The invention according to claim 15 is characterized in that, in the electronic medical record creation system, a server for storing the electronic medical record created so far, a medical image diagnostic apparatus for acquiring a medical image necessary for creating the electronic medical record, and repetition A storage unit that stores the contents of the entry subject to prescription or order, a display unit that displays the contents of the entry, and whether to repeatedly prescribe or order the contents of the displayed entry are entered. Input section for determining, risk level determining section for determining the risk level of each entry , determining section for determining confirmation conditions based on the risk level determined by the risk level determining section, and depending on the confirmation conditions and determines a screen display of the display mode for confirming whether to be repeated prescription or order confirmation items, risk level determination And an electronic medical record creation device and a display mode decision unit for instructing the display unit to display the display mode based on the risk level determined for each principal confirmation item by.

According to a sixteenth aspect of the present invention, in the electronic medical record creation system, a server for storing the electronic medical record created so far, a medical image diagnostic apparatus for acquiring a medical image necessary for creating the electronic medical record, and repetition Whether to repeat the prescription or order for the contents of the storage part that stores the contents of the entry of the medical order subject to prescription or order, the display part that displays the contents of the entry, and Input section for input, risk level determination section for determining the risk level of each entry, determination section for determining confirmation conditions based on the risk level determined by the risk level determination section, and according to the confirmation conditions Determine the display mode of the screen display for confirming the pros and cons of repeatedly prescribing or ordering the required confirmation items. Comprising a display mode decision unit for instructing the display of the display mode determined to the display unit for each item, the decision unit determines a table示態like display frequency based on the risk level as one of the confirmation conditions And an electronic medical record creation device characterized by:

It is a block diagram which shows the whole structure of the electronic medical chart production system containing the electronic medical chart production apparatus in embodiment. It is a block diagram which shows the internal structure of the electronic medical record preparation apparatus in embodiment. It is a block diagram which shows the internal structure of the Do display part in embodiment. It is a flowchart which shows the flow from Do display in embodiment to the confirmation of the said display content. It is a flowchart which shows the flow from Do display in embodiment to the confirmation of the said display content. It is an example of the table which shows the risk level of the confirmation required item in embodiment. It is an example of the table which shows the confirmation conditions of the risk level in embodiment. It is explanatory drawing for demonstrating an example of the confirmation conditions in embodiment. It is an example of a screen which shows an example of the display screen in embodiment. It is an example of a screen which shows an example of the display screen in embodiment. It is an example of a screen which shows an example of the display screen in embodiment.

  Hereinafter, embodiments of the present invention will be described in detail with reference to the drawings.

  FIG. 1 is a block diagram illustrating an overall configuration of an electronic medical record creation system S including an electronic medical record creation apparatus 3 according to the embodiment. The electronic medical record creation system S is used to create a server 1 for storing the electronic medical record created so far, a medical image diagnostic apparatus 2 for obtaining a medical image necessary for creating the electronic medical record, and an electronic medical record. The electronic medical chart creation device 3 and a communication network N that connects them to each other. The electronic medical record creation system S may be configured as an independent system, for example, a hospital information management system (HIS), a radiology information management system (RIS), a medical image management system. All or some of various management systems built in a medical institution such as a system (PACS: Picture Archiving Communication System) may be configured.

  The server 1 is an apparatus that stores the electronic medical chart created by the electronic medical chart creating apparatus 3. The server 1 may store not only the electronic medical record but also internal information (medical image) of the patient acquired by the medical image diagnostic apparatus 2 described later, for example.

  The medical image diagnostic apparatus 2 is a medical image acquisition (imaging) apparatus that images a patient and acquires internal information thereof. Examples of the medical image diagnostic apparatus 2 include an X-ray CT apparatus (computed tomography) and a magnetic resonance diagnostic apparatus (MRI).

  The electronic medical record creation apparatus 3 is a workstation used when, for example, a doctor or the like uses a medical image to examine a patient or interprets a medical image to create an electronic medical record. In the following, although there is no particular limitation, for example, an electronic medical record creation apparatus 3 itself may hold an application for creating an electronic medical record, and the electronic medical record may be created using the application.

  Alternatively, the application is stored in the server 1 as a thin client system, and when creating an electronic medical record, the electronic medical record creation apparatus 3 may access the server 1 and use this application. In this case, it is sufficient for the electronic medical record creation apparatus 3 to have at least processing capability for requesting and displaying information necessary for creating the electronic medical record from the server 1.

  In the medical image system S shown in FIG. 1, a server 1, a medical image diagnostic apparatus 2, and an electronic medical chart creation apparatus 3 are connected to the communication network N one by one. However, the number of servers, medical image diagnostic apparatuses, or electronic medical record creation apparatuses connected to the communication network N may be either singular or plural, and the number is arbitrary.

  The communication network N connects the server 1, the medical image diagnostic apparatus 2, and the electronic medical record creation apparatus 3, and enables, for example, exchange of medical image information between them. Examples of the communication network N include a network such as a LAN (Local Area Network) and the Internet. In addition, the standard regarding information exchanged via the communication network N may be any standard such as DICOM (Digital Imaging and Communication in Medicine).

  FIG. 2 is a block diagram showing an internal configuration of the electronic medical record creation apparatus 3 according to the embodiment of the present invention.

  In the electronic medical chart creation apparatus 3, a CPU (Central Processing Unit) 3a, a ROM (Read Only Memory) 3b, a RAM (Random Access Memory) 3c, and an input / output interface 3d are connected via a bus 3e. An input unit 3f, a display unit 3g, a communication control unit 3h, a storage unit 3i, and a removable disk 3j are connected to the input / output interface 3d. In addition, a Do display unit 10 is also connected to perform processing necessary for Do display.

  Here, ““ Do description (Do display) ”is a display indicating that the prescription or order described in the previous chart is repeated or the description is the same when ordering repeatedly. It is.

  The CPU 3a reads out and executes a boot program for starting the electronic medical record creation apparatus 3 from the ROM 3b based on an input signal from the input unit 3f, and reads out various operating systems stored in the storage unit 3i. The CPU 3a controls various devices based on input signals from other external devices not shown in FIG. 3 via the input unit 3f and the input / output interface 3d.

  Further, the CPU 3a reads the program and data stored in the RAM 3c, the storage unit 3i, and the like, loads them into the RAM 3c, and confirms the confirmation items to be confirmed when performing Do display based on the program commands read from the RAM 3c. And a processing device that implements a series of processes such as calculation and processing of data.

  The input unit 3f is configured by an input device such as a keyboard and a dial through which an operator (for example, a doctor) of the electronic medical record creation apparatus 3 inputs various operations. Based on the operation of the operator, the input unit 3f creates an input signal, and the input signal is transmitted to the CPU 3a via the bus 3e. In addition, a mouse, a card reader, a barcode reader, a touch panel, a microphone, a camera, and the like can be cited as a kind of the input unit 3f.

  The display unit 3g is a monitor such as a liquid crystal display. The display unit 3g receives an output signal from the CPU 3a via the bus 3e, and displays, for example, an image necessary for setting conditions for processing an image in the electronic medical record creation apparatus 3, or a processing result of the CPU 3a. To do. The display unit 3g includes a printer, a projector, a speaker, and other devices that appeal to the five senses of the person who creates the electronic medical record.

  The communication control unit 3h is a means such as a LAN card or a modem, and is a means that enables the electronic medical record creation apparatus 3 to be connected to a communication network N such as the Internet or a LAN. Data transmitted / received to / from the communication network via the communication control unit 3h is transmitted / received to / from the CPU 3a via the input / output interface 3d and the bus 3e as an input signal or an output signal.

  The storage unit 3i is composed of a semiconductor or a magnetic disk, and stores a program and data for performing Do display, for example, executed by the CPU 3a. Further, a table and confirmation conditions relating to risk levels, which will be described later, are also stored.

  The removable disk 3j is an optical disk or a flexible disk. A signal read / written by the disk drive is transmitted / received to / from the CPU 3a via the input / output interface 3d and the bus 3e. An application necessary for Do display processing is stored in the removable disk 3i via the storage unit 3i or an external storage medium.

  The Do display unit 10 has a function for performing Do display, which is one process when a doctor who creates an electronic medical record creates an electronic medical record. Accordingly, the function of the Do display unit 10 is executed with the trigger of the process for triggering the Do display by the person who creates the electronic medical chart.

  FIG. 3 is a block diagram showing an internal configuration of the Do display unit 10 according to the embodiment of the present invention. The Do display unit 10 includes, for example, a reception unit 11 that receives a request for executing Do from a person who creates an electronic medical record, a determination unit 12, a risk level determination unit 13, a determination unit 14, and a display mode determination. The unit 15 and a transmission unit 16 that transmits a confirmation screen for the confirmation item required for confirmation of the confirmation item to the display unit 3g.

  The functions and functions of these units will be described together with the description of the flow from the Do display described below to the confirmation of the display content.

  Next, the method of Do display, that is, the doctor who is the person who creates the electronic medical record after selecting the item to be displayed, confirms the item, and the order until Do display is made as a result. I will explain later. In addition, the case where it repeats and prescribes as an example among the Do display regarding the prescription or order performed repeatedly here is demonstrated below as an example.

  4 and 5 are flowcharts showing a flow from Do display to confirmation of the display content in the embodiment.

  When creating an electronic medical chart, a person who creates an electronic medical chart, for example, reads out and uses a medical chart template from the server 1. In addition, in order to assist in the examination of the patient and the creation of the medical chart, the medical chart relating to the patient created so far may be read out and displayed on the display unit 3g of the electronic medical chart creation apparatus 3. Since the flow of creating these electronic medical records is known, the description thereof is omitted here.

  While a doctor prepares a medical chart, for example, it is possible to describe the contents of treatments and findings, or the same contents as past medical charts that have been created so far for prescription of drugs. At that time, the corresponding contents from the past medical record are reflected in the current medical record in a manner of copy and paste.

  Against this background, there is a tendency for the contents to be described in the medical record to increase, and if all are described every time a medical examination is performed, the burden on the doctor who creates the medical chart increases. On the other hand, the medical record itself becomes an electronic medical record, such as the performance improvement of the electronic medical record preparation apparatus 3 and the construction of the electronic medical record preparation system S. The state where the act of creating the document itself can be easily and conveniently created has been created.

  Therefore, if Do display can be easily performed under such circumstances, it is possible that the check (confirmation) regarding the Do display content is not achieved while improving the convenience of creating a chart. Therefore, it is important how a doctor who creates an electronic medical record confirms the content to be displayed Do.

  When Do display is performed, first, a range (item) in which Do display is performed is selected by a person who creates the electronic medical record, so the electronic medical record creation apparatus 3 grasps the selected item (ST1). . However, at this stage, it cannot be determined whether or not Do display is actually performed. This is because, in the electronic medical record creation system S, for example, clicking a button for performing Do display requires a certain intention display from the person who creates the electronic medical record in performing Do display. Therefore, the electronic medical record creation apparatus 3 determines whether or not the selected item is a target of Do display (ST2).

  Note that whether or not Do display is performed on the selected item in the Do display unit 10 can be arbitrarily set. For example, when the determination is performed in the Do display unit 10, the determination unit 12 determines whether the selected item is a target of Do display. In the case where the determination is made in the electronic medical chart creation apparatus 3, for example, the determination is performed in the CPU 3a. The following description will be made on the assumption that the determination unit 12 determines whether the selected item is a target of Do display.

  If the Do is not displayed for the selected item as a result of the determination (NO in ST2), the doctor himself / herself enters the treatment and prescription in the electronic medical record. Therefore, although it is understood that the item has been selected here, the process is terminated when the Do display is not performed.

  On the other hand, when the doctor has indicated the intention to display Do (YES in ST2), preparation for performing Do display on the selected item is started. The Do display unit 10 (determination unit 12) acquires information about the selected item from the storage unit 3i (ST3). The information related to the item includes, for example, information related to the medicine shown in the item and information about whether or not the item is to be confirmed.

  Accordingly, the determination unit 12 determines whether or not the selected item (item scheduled to be displayed Do) is a confirmation required item based on these pieces of information (ST4). Here, “required items” are important items related to treatment, prescription, etc., among the selected items, so it is necessary to confirm the person (doctor) who creates the electronic medical record in some form before displaying Do It is an item.

  For this reason, even if the item is selected, if it is not determined that the item needs to be confirmed (NO in ST4), there is no problem even if the Do is displayed as it is without confirmation from the doctor. In this case, it is determined again whether or not the next item is a confirmation required item.

  Next, when it is determined that the selected item is a confirmation required item (YES in ST4), the determination unit 12 specifies an item to be confirmed and determines a risk level for the confirmation required item. (ST5). The determination unit 12 determines a risk level for each item via the risk level determination unit 13.

  That is, first, for example, information related to items such as a name and prescription amount relating to a drug is compared with information related to a drug stored in advance in the storage unit 3i and a standard prescription amount of the drug. Moreover, the characteristics of the drug are also acquired from the name of the drug. Based on these pieces of information, the risk level relating to the drug to be displayed in Do and the prescription amount thereof is grasped.

  FIG. 6 is an example of a table indicating the risk level of the items to be confirmed in the embodiment. According to this table, the vertical axis shows the characteristics of the medicine, and here, three levels are shown. The reason why the characteristics of a drug are grasped when determining the risk level is that the risk level varies greatly depending on the characteristics.

  The characteristics are set using, for example, characteristics defined in NDP (National Demonstration Project). Here, since the purpose is to prompt the doctor to confirm the treatment, prescription, etc., which is the object of Do display, any definition may be used to define the characteristics. Further, the level of characteristics is described in three steps in the table shown in FIG. 6, but the number of levels is arbitrary.

  In addition, the risk level table shown in FIG. 6 does not define drugs that are unlikely to cause serious results when prescribed to patients. This is because in this embodiment, it is determined that such a medicine is not included in the confirmation required items.

  Therefore, it is possible to arbitrarily set to what level the characteristics of the drug are defined in the table indicating the risk level. Therefore, it is also possible to determine the risk level of a drug that is unlikely to cause a serious result, and allow the person who creates the electronic medical record to determine the confirmation conditions described later.

  On the other hand, the horizontal axis indicates an appropriate range regarding the prescription amount of the drug. Here, centering on being in the proper range, three levels are shown when the prescription amount is larger than the proper range and small. In general, there is no problem in prescribing the patient if the prescription amount of the drug is in the proper range, but here the risk level is set in relation to the characteristics of the drug, so the prescription The risk level is also set when the amount is within the appropriate range.

  For example, when the drug characteristic is “drug with strong toxicity of the component itself”, the risk level is determined as “A” regardless of the prescription amount. Here, in the table shown in FIG. 6, three levels “A”, “B”, and “C” are shown as risk levels, and the risk level decreases from “A” to “C”. . For example, when the drug characteristic is “drug with drug interaction that can cause serious consequences” and the prescribed amount is “smaller than appropriate range”, the risk level is determined as “C”. The This is because this combination is judged to have a lower risk level than in the case of a “drug with strong toxicity of the component itself” having a risk level of A.

  Some drugs may interact with each other. In this case, a risk level may be determined by defining a combination of a plurality of drugs in a table. Regarding the combination of drugs, in addition to the interaction, the relationship between the newly prescribed drug at the time of performing the Do display operation and the previously prescribed drug that still has an effective deadline at that time is also judged. The In addition, since medical charts are changed when different medical departments are used, it is necessary to check the combination of medicines provided in the respective medical departments.

  In addition, in relation to the display described later, for example, when there are multiple drugs that have been determined to have a medium risk level, it may be possible to combine these risk levels and re-determine a higher risk level. It is done. This is because doctors will check more carefully at such high risk levels. Also, if the number of drugs that show the same level of risk increases, the display becomes diffuse, resulting in the same display as all items, and the necessary information cannot be delivered to the doctor. . Therefore, by displaying several display patterns, it is possible to ensure confirmation of items requiring confirmation having a particularly serious risk level. Such setting can be made arbitrarily in advance.

  The risk level determination unit 13 determines the above risk level. Further, as described above, since the table defining the risk level is stored in the storage unit 3i in the embodiment of the present invention, the necessary risk level is accessed by accessing the storage unit 3i from the risk level determination unit 13. decide. Here, the table defining the risk level is stored in the storage unit 3i of the electronic medical record creation apparatus 3 here, but for example, a database is provided in the Do display unit 10 and may be stored in this database. good.

  The risk level determination unit 13 confirms whether or not it is necessary to further adjust the overall risk level with respect to the risk level related to the drug of the confirmation required item once determined (ST6). Here, the “overall risk level” means that the risk level is set not only in the medical institution where the electronic medical record creation system S is constructed, but also in a wide area including the area where the medical institution is installed. It assumes the risk level that is commonly set in medical institutions. Further, for example, a risk level set in a medical corporation group including the medical institution can be considered.

  If such an overall risk level is designated, the risk level determination unit 13 adjusts the risk level once determined. For example, when “all risk levels are raised by one level” as the “overall risk level” (YES in ST6), the risk level is adjusted according to the specification (ST7). ). For example, if the risk level once determined is “B”, the risk level is “A” by adjustment. Further, when the risk level is already “A”, for example, it is possible to cope with the risk level “AA” or leave it as “A”.

  On the other hand, if there is no overall risk level adjustment (NO in ST6), or if the overall risk level adjustment is completed (ST7), then whether or not individual risk level adjustments are made Confirm (ST8).

  This “individual risk level” is based on, for example, the attributes of a doctor who is an electronic medical record creator. That is, about the doctor who produces an electronic medical record, for example, years of experience, age, etc. are each. Therefore, for example, when the doctor has little experience such as less than 3 years of experience or is elderly, the risk level is increased so as to positively confirm the Do display.

  As to whether or not the risk level needs to be adjusted based on this “individual risk level”, for example, a doctor input when creating an electronic medical record can be uniquely specified. Judgment based on. The determination is performed by, for example, the determination unit 12 and the result is transmitted to the risk level determination unit 13. The risk level determination unit 13 adjusts individual risk levels based on the result (YES in ST8, ST9) or does not adjust (NO in ST8).

  Here, for example, when the individual risk level needs to be adjusted, it is possible to set the risk level to be increased by one. It is also possible to finely set and adjust the fluctuation of the risk level according to the attributes of the doctor. In some cases, the risk level may be lowered.

  Regarding the determination of the risk level and the adjustment of the risk level described above, either process may be performed first or both may be performed in parallel.

  When the risk level is finally determined for each item to be confirmed in the risk level determination unit 13, the determination condition is determined in the determination unit 14 (ST10 in FIG. 5). Here, the “confirmation condition” is a condition for confirmation performed by a doctor who is a person who creates an electronic medical record based on a risk level determined for each item to be confirmed.

  FIG. 7 is an example of a table showing risk level confirmation conditions in the embodiment. In the table, “confirmation conditions” associated with “risk level” are defined. For example, when the risk level is “A”, the confirmation condition is “confirmation by operation”. That is, when the risk level of the confirmation required item is A, the doctor who creates the electronic medical record confirms whether or not the item to be displayed in the Do display is appropriate when performing the Do display. It is necessary to perform processing. In addition, as the Do display unit 10, a screen display that allows the doctor to perform an operation for confirmation in the display mode determination unit 15 is generated and displayed on the display unit 3 g.

  On the other hand, when the risk level is “B”, the confirmation condition is “display is 3 seconds or more”. This means that the display for confirming the display on the display unit 3g is displayed for “3 seconds or more”. Of course, the display time can be arbitrarily set.

  When the risk level is “C”, the confirmation condition is “confirmation should be performed once every two times”. The number of times here is the number of times of creating an electronic medical record. Therefore, “confirmation at a rate of once every two times” will be described by taking the case of newly creating an electronic medical record as an example. For the confirmation items of risk level C at the time of the previous electronic medical chart creation, In the case of confirmation, regarding the contents previously displayed as “Do” last time, it is necessary to confirm the necessary confirmation items again this time. On the other hand, if confirmation was made at the time of the previous electronic medical record creation, it is not necessary to confirm the current electronic medical record creation.

  Therefore, in this case, information regarding whether or not the confirmation process has been performed on the necessary confirmation item before must be grasped. For example, the information may be stored in the storage unit 3 i of the electronic medical record creation apparatus 3.

  In addition to the above-described conditions, for example, the confirmation condition may be a condition that a confirmation is always performed when a certain period of time has elapsed, or a plurality of confirmation conditions may be used in appropriate combination.

  For example, a case will be described as an example where there are confirmation conditions of “period in which confirmation is required for each drug” and “period in which Do display is performed (interval at which a patient is examined)”. FIG. 8 is an explanatory diagram for explaining an example of the confirmation condition in the embodiment.

  FIG. 8 shows two upper and lower number lines, the upper number line α indicates the “period in which confirmation is required for each drug”, and the lower number line β indicates “Do display”. Period (interval at which the patient is examined) ". As the “period in which confirmation is required for each medicine”, for example, it is assumed that confirmation is required every two weeks. Therefore, in the number line α, one scale represents one week, and a triangular mark is added every two weeks that need to be confirmed. On the other hand, it is assumed that the interval between patient examinations, that is, the period during which Do display is performed is “5 days”. Therefore, in the number line β, 5 days of the period in which Do is displayed is represented as one scale. In addition, the beginning of the number line indicates the time point when the patient is examined. In some cases, the patient is first prescribed a medicine for the patient, and the doctor who creates the electronic medical record newly enters the prescription for the medicine in the electronic medical chart. Accordingly, Do is displayed at the subsequent examination.

  As described above, here, the “period for which confirmation is required for each drug” is set every two weeks. Therefore, there are two examinations (opportunities for Do display) during this period. However, at the time of these two examinations, since the two weeks of “the period for which confirmation is required for each drug” has not elapsed since the prescription of the drug was first prescribed, the degree of confirmation should be reduced. It is possible. On the other hand, when the third examination (the fourth examination in total) is performed from the first examination, two weeks of “a period for which confirmation is required for each drug” will elapse. The person who creates the medical chart needs sufficient confirmation. Thus, by using a combination of a plurality of confirmation conditions as appropriate, a person who creates an electronic medical record can perform more necessary and appropriate confirmation.

  In addition, by appropriately changing the above-described confirmation frequency according to, for example, the type of medicine, the confirmation period, and the like, the “concentration of confirmation” for the confirmation target of the person who creates the electronic medical record can be made appropriate. . This leads to a more reliable confirmation because it makes a clear confirmation for the person who creates the electronic medical record.

  In the case where the confirmation condition is determined by the determination unit 14 for the confirmation necessary item, it is further confirmed whether or not the confirmation necessary item is selected (ST11). As a result of determination by the determination unit 12, if there are still confirmation items for which the risk level and confirmation conditions have not been determined (YES in ST11), the process returns to step ST4 and the above-described series of processing is performed ( (See FIG. 4).

  On the other hand, when the risk level and the confirmation condition are determined for all items, the display mode is determined in the display mode determination unit 15 for the confirmation required item, and the doctor is notified of the confirmation (ST12). As for the notification here, in addition to a method of displaying a display for confirmation on the display unit 3g, a voice notification that the doctor reads the confirmation items as will be described later, or that the electronic medical record creation device 3 reads the confirmation items. This method is also conceivable. Therefore, the display mode determination unit 15 also supports voice notification. In FIG. 5, the flow is described on the assumption that a screen for performing a confirmation process by a doctor is displayed on the display unit 3g.

  FIG. 9 is a screen example showing an example of a display screen in the embodiment. The display mode determination unit 15 determines a display (notification) mode for confirming whether or not to perform Do display according to the confirmation condition, based on the confirmation condition determined by the determination unit 14.

  In the screen example X shown in FIG. 9, an area for displaying information about the patient is provided in the upper stage. In addition, an area for inputting a situation obtained by the examination is provided on the left side, and an area for displaying a prescription drug or the like is provided on the right side. Here, it is a case where Do is displayed about a medicine based on a past medical record. Two types of drugs displayed in Do are displayed, and the screen for confirming whether or not to display Do for the doctor who is the creator of the electronic chart for “Alkeran” is the screen for creating the electronic chart. It is displayed above. Here, it is confirmed whether or not “alkeran”, which is an anticancer agent, is prescribed again, that is, whether or not it is described in the medical chart by Do display.

  The doctor needs to confirm and approve the display by clicking the confirmation button in order to display the “alkeran” in Do.

  Whether or not the confirmation process by the doctor has been performed is determined by the determination unit 12 (ST13). For example, it is whether or not the confirmation button on the screen as shown in FIG. 9 has been clicked by the doctor. When confirmation by the doctor is not made (NO in ST13), for example, after waiting for a predetermined time, it is confirmed whether further confirmation processing has been performed (NO in ST14). Here, whether or not to provide a standby time for determining whether or not the confirmation process has been performed can be arbitrarily set. Similarly, the standby time can be arbitrarily set.

  If the confirmation process is not performed within the predetermined waiting time (YES in ST14), it means that the doctor has not confirmed the necessary confirmation item, and the process for displaying Do itself is stopped (ST15). ). This is because the Do display without confirmation can lead to prescribing the medicine without the approval of the doctor. Specifically, processing is performed so that Do display cannot be performed by a method in which the confirmation process becomes invalid or, for example, a range selected for Do display is canceled.

  When the confirmation process by the doctor is performed (YES in ST13), it is confirmed whether there is a next confirmation required item (ST16). If the determination unit 12 determines that there is a next item to be confirmed (YES in ST16), the process returns to step ST12 and the confirmation process by the doctor is performed. Here, although a doctor's confirmation process is requested for each confirmation item required, for example, depending on conditions such as the number of confirmation items, it may be considered that the confirmation items are collectively sent to the confirmation process.

  As for the display mode of the confirmation required item, the display mode determination unit 15 checks the size of the displayable area in the display unit 3g and determines the display mode based on the area. If the display area is large and it is determined that all the Do display targets can be displayed, including the confirmation required items, all the targets are displayed. On the other hand, if it is determined that it is difficult to display all Do display targets because the display area is small, only the confirmation items that are necessary are extracted and only the confirmation items that are necessary are displayed. Of course, it is possible to adopt a mode in which only items with a high risk level are displayed among the items requiring confirmation according to the size of the display area.

  In addition, even if all the Do display targets cannot be displayed at once, the display screen is automatically scrolled, and when the confirmation item is displayed, the scrolling is temporarily stopped. There is also a display method of displaying a confirmation screen for the doctor. Furthermore, any method may be adopted as long as it requires a doctor's attention and prompts confirmation, such as displaying a list of items requiring confirmation separately, or displaying only the items requiring confirmation by changing the font or display color. May be.

  When there is no next required confirmation item (NO in ST16), confirmation processing is completed for all the necessary confirmation items among the selected items, and thus the confirmation processing ends (ST17). In this state, all of the selected items are displayed as Do (ST18).

  10 and 11 are other screen examples showing examples of display screens in the embodiment. 10 and 11 show a case where the confirmation process by the doctor is performed on the screen of the portable information terminal (electronic medical record creation apparatus 3A).

  In the future, further spread of portable information terminals, represented by iPad (registered trademark), can be considered. In addition, doctors may use these portable information terminals in various places and scenes. Therefore, confirmation of the Do display by the doctor must be performed reliably even on a more compact screen.

  For example, in the screen example Y of FIG. 10, the past treatment and prescription are entered in the areas indicated by A and B, while the current treatment and prescription are entered in the areas indicated by C and D. It will be. Further, below the middle part of the screen example Y, two tabs each having “treatment Do” and two tabs having “prescription Do” are shown. By operating this tab, the contents described in the areas indicated by A and B can be displayed Do in the areas indicated by C and D.

  FIG. 11 shows a confirmation screen for performing Do display. Here, it is a screen related to the confirmation process regarding the prescription of the medicine (“prescription Do confirmation” is at the top of the screen). In the screen example Z, two types of drugs are displayed, and a confirmation screen for displaying Do for the drug “bonalon” is displayed. Here, we change the color of the area that shows the items that need confirmation, and clarify the subject, and the message “There is one kind of powerful drug (color change) included. Please read it out.” Is displayed. Accordingly, in this screen example Z, whether or not to perform Do display is confirmed by letting a doctor say an item to be confirmed.

  After the doctor reads out, the confirmation process is performed by tapping the “Do execution” portion. In addition, for example, the electronic medical record creation apparatus 3A may grasp the voice read out by the doctor, perform the confirmation process, and then perform “Do execution”.

  As described above, when Do display is performed in creating an electronic medical chart, not only Do display is instructed, but the confirmation priority is determined for each displayed item, and the screen display is based on the priority. By doing so, it is possible to provide an electronic medical chart creation apparatus and an electronic medical chart creation system capable of easily and reliably confirming the Do display of items to be confirmed.

  As a result, it is possible to reduce instruction and transmission errors due to Do display.

  Although an embodiment of the present invention has been described, this embodiment is presented as an example and is not intended to limit the scope of the invention. This embodiment can be implemented in various other forms, and various omissions, replacements, and changes can be made without departing from the spirit of the invention.

  For example, regarding Do display, the risk level and the confirmation conditions corresponding to the risk level are determined depending on whether the Do display is performed to confirm various contents in advance or the confirmation process is performed so that the Do display is actually performed. It is also possible to adopt a method of changing both. In this case, the confirmation step for the person who creates the electronic medical record increases, so a method of lowering the risk level at the initial stage is also conceivable.

  In the description so far, drug prescription has been described as an example. However, the present invention is not limited to the prescription (order) of the drug, and can also be applied to the case where Do display is performed for various medical orders such as an injection order, a treatment order, or a test order. Here, the “injection order” means an order for performing a treatment of performing an injection or an order of a medicine to be put into the injection. The “treatment order” is an order of treatment performed after a medical examination (an electronic medical record is created). Furthermore, the “examination order” indicates the order of the examination for the patient.

  This embodiment and its modifications are included in the scope and gist of the invention, and are included in the invention described in the claims and the equivalents thereof.

DESCRIPTION OF SYMBOLS 1 Server 2 Medical image diagnostic apparatus 3 Electronic medical record preparation apparatus 10 Do display part 11 Reception part 12 Determination part 13 Risk level determination part 14 Determination part 15 Display mode determination part 16 Transmission part

Claims (16)

A storage unit for storing the contents of entries to be repeatedly prescribed or ordered;
A display unit for displaying the contents of the entry;
An input unit for inputting whether to repeat the prescription or order for the content of the displayed entry;
A risk level determination unit that determines a risk level of each of the entries;
A determination unit for determining a confirmation condition based on the risk level determined in the risk level determination unit;
Depending on the check condition, and determines a screen display of the display mode for the main confirmation item to check whether to be the repeating formulation or order, it is determined for each of the principal confirmation item by the risk level determination unit A display mode determination unit that instructs the display unit to display the display mode according to the risk level ;
An electronic medical record creation apparatus comprising: The risk level determination unit is based on an overall risk level that is predetermined based on general information and an individual risk level that is determined based on an attribute of a person who creates an electronic medical record. The electronic medical record creation apparatus according to claim 1 , wherein a confirmation condition is set for a confirmation required item. If it is determined that checking the main check item, the repeat prescription or electronic medical record creation device according to claim 1 or claim 2, characterized in that it comprises a determination unit that makes determination of possible implementation of the order . The display mode determination unit determines a display order on the display unit with reference to the risk level determined by the risk level determination unit for the entry item or the confirmation required item. The electronic medical chart preparation apparatus in any one of Claim 1 thru | or 3 . The display mode determination unit performs the determination as the display mode that prompts the person who prepares the electronic medical record to repeatedly prescribe or order the required check item according to the content of the required check item. The electronic medical record creation apparatus according to any one of claims 1 to 4 , wherein the electronic medical record creation apparatus is characterized. The determination unit prompts the person who creates the electronic medical record to confirm that the required confirmation item is repeatedly prescribed or ordered, based on the display time of the required confirmation item on the display unit. The electronic medical record creation apparatus according to claim 3 , wherein it is determined that repetitive prescription or ordering has been confirmed. The display mode determination unit is configured to cause the person who prepares the electronic medical record to repeatedly prescribe or order the required confirmation item according to the content of the required confirmation item, and to perform the confirmation and approval by the operation. The electronic medical record creation apparatus according to any one of claims 1 to 4 , wherein the determination as an aspect is performed. When the determination unit receives information indicating that the confirmation button displayed on the display unit has been clicked by a person who creates the electronic medical record with respect to the content of the confirmation required item, the determination unit repeats the confirmation required item. It is judged that it was confirmed about prescription or ordering, The electronic medical record preparation apparatus of Claim 3 characterized by the above-mentioned. The determination unit repeatedly prescribes or orders the required confirmation items by reading out the required confirmation items that are repeatedly prescribed or ordered by the person who creates the electronic medical record with respect to the contents of the required confirmation items. The electronic medical record creation apparatus according to claim 3 , wherein the electronic medical record creation apparatus is determined to have been confirmed. The display mode decision unit, the electronic medical record generating apparatus according to any of claims 1 to 9, characterized in that selecting a display method of the screen displayed in response to quantity of the principal confirmation item. The display mode decision unit, an electronic medical record created according to any one of claims 1 to 10, characterized in that selecting a display method of the image display according to the size of the display area of the main check item apparatus. A storage unit for storing the contents of entries of medical orders that are subject to repeated prescriptions or orders;
A display unit for displaying the contents of the entry;
An input unit for inputting whether to repeat the prescription or order for the content of the displayed entry;
A risk level determination unit that determines a risk level of each of the entries;
A determination unit for determining a confirmation condition based on the risk level determined in the risk level determination unit;
Depending on the check conditions, a main check item and determines a screen display of the display mode for confirming whether to be the repeating formulation or order, the determined for the display unit for each main check item A display mode determination unit for instructing display of the display mode,
The determination unit determines the display frequency of the display mode according to the risk level as one of the confirmation conditions. 13. The electronic medical record creation apparatus according to claim 12 , wherein the display frequency is determined based on contents of the entry items of the medical order. The electronic device according to claim 12 or 13 , wherein the display frequency is determined from a relationship between a confirmation interval for each medical order and a treatment based on the medical order or a date on which a prescription is made. Medical chart creation device. A server for storing the electronic medical records created so far,
A medical image diagnostic apparatus for obtaining a medical image necessary for creating the electronic medical record;
An electronic medical record creation apparatus according to any one of claims 1 to 11 ,
An electronic medical record creation system comprising: A server for storing the electronic medical records created so far,
A medical image diagnostic apparatus for obtaining a medical image necessary for creating the electronic medical record;
An electronic medical record creation apparatus according to any one of claims 12 to 14 ,
An electronic medical record creation system comprising:

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