JP6733504B2 - Electronic medical record system and electronic medical record program - Google Patents

Description

The present invention relates to an electronic medical record system and an electronic medical record program.

In recent years, in medical institutions such as hospitals, an electronic medical chart system (for example, refer to Patent Document 1) that manages medical information regarding medical treatment of patients with electronic data called an electronic medical chart is used. The input to the electronic medical chart can be performed using, for example, a keypad displayed on the touch panel display.

Japanese Patent No. 4811383

By the way, in an electronic medical record, it is required that the responsibility of preparation is clarified, that is, it is clear from the viewpoint of a third party when and who created it. Therefore, in an electronic medical chart system, it is general to record the user (for example, a doctor) who finally saved the electronic medical chart and the date and time of the storage.

However, if only the user who finally saved the electronic medical record and the save date and time are recorded, a plurality of users (for example, a doctor, a clerk, a nurse, an associate nurse) can record a plurality of information ( When the medical record information is written sequentially, it is not known when and who wrote each medical record information.

It is an object of the present invention to provide an electronic medical record system and an electronic medical record program that can identify when and who wrote individual medical record information described in an electronic medical record.

Electronic medical record system according to the present invention, as described processing unit for placing serial mosquitoes lutein information to the electronic medical record in response to a user operation, each time a new medical record information is added to the same electronic chart by the described processor, An acquisition processing unit for acquiring writer information including writer identification information indicating a writer of the medical record information and description date/time information indicating a description date/time of the medical record information, and the writer information acquired by the acquisition processing unit. a and a storage processing unit that stores in the storage unit in association with the new medical record information.

Electronic chart program according to the present invention, as described processing step of placing serial medical record information in the electronic chart in response to a user operation, each time a new medical record information is added to the same electronic medical record in the described processing steps, the The acquisition processing step of acquiring the writer information including the writer identification information indicating the writer of the medical record information and the description date/time information indicating the description date/time of the medical record information, and the writer information acquired in the acquisition processing step. , an electronic medical record program for executing a storage processing step of storing in the storage unit in association with the new medical record information to the processor.

According to the present invention, there are provided an electronic medical record system and an electronic medical record program that can identify when and who wrote individual medical record information described in an electronic medical record.

FIG. 1 is a diagram showing a configuration of an electronic medical chart system according to an embodiment of the present invention. FIG. 2 is a diagram showing an example of an account management screen displayed in the electronic medical record system according to the embodiment of the present invention. FIG. 3 is a diagram showing an example of an account management master used in the electronic medical record system according to the embodiment of the present invention. FIG. 4 is a diagram showing an example of a medical record screen displayed by the electronic medical record system according to the embodiment of the present invention. FIG. 5 is a diagram showing an example of a medical record screen displayed by the electronic medical record system according to the embodiment of the present invention. FIG. 6 is a diagram showing an example of XML information used in the electronic medical record system according to the embodiment of the present invention. FIG. 7 is a diagram showing an example of a medical record screen displayed on the electronic medical record system according to the embodiment of the present invention. FIG. 8 is a diagram showing an example of an electronic medical chart process executed by the electronic medical chart system according to the embodiment of the present invention.

Hereinafter, embodiments of the present invention will be described with reference to the accompanying drawings to provide an understanding of the present invention. Note that the following embodiments are examples embodying the present invention, and are not of the nature to limit the technical scope of the present invention.

[Electronic medical record system 1]
As shown in FIG. 1, an electronic medical chart system 1 according to an embodiment of the present invention includes an electronic medical chart device 10, one or more client terminals 20, and a printer 30. The electronic medical chart device 10, the client terminal 20, and the printer 30 can communicate with each other via a network 40 such as a LAN or the Internet.

[Electronic chart device 10]
The electronic medical chart device 10 is a computer including a control unit 11, a storage unit 12, a display unit 13, an operation unit 14, a communication IF 15, a drive device 16, and the like. The electronic medical chart device 10 is provided inside or outside a medical institution such as a hospital or a pharmacy in which the electronic medical chart device 10 is used. That is, the electronic medical chart device 10 may be provided outside the medical institution, and the client terminal 20 may be provided in the medical institution.

The electronic medical record apparatus 10 is capable of performing an editing process such as writing and updating information (medical record information) in an electronic medical record including medical information of a patient according to an operation of the client terminal 20. Equipped with. Further, the electronic medical chart device 10 may have a function of a receipt computer processing system capable of executing accounting processing such as registration and update of accounting information according to an operation of the client terminal 20.

The control unit 11 has control devices such as a CPU, a ROM, a RAM, and an EEPROM (registered trademark). The CPU is a processor that executes various arithmetic processes. The ROM is a non-volatile storage unit in which information such as a control program for causing the CPU to execute various processes is stored in advance. The RAM is a volatile storage unit, and the EEPROM is a non-volatile storage unit. The RAM and the EEPROM are used as a temporary storage memory (work area) for various processes executed by the CPU. Then, the control unit 11 uses the CPU to execute various processes according to various control programs stored in the ROM, the EEPROM, or the storage unit 12 in advance.

The storage unit 12 is a non-volatile storage unit such as a hard disk drive, an SSD (Solid State Drive), or a flash memory in which various control programs executed by the control unit 11 and various data are stored. Specifically, the storage unit 12 has storage areas such as a program area 121, a master area 122, and a data area 123.

The program area 121 stores an electronic medical record program for causing the control unit 11 to execute various processes such as an electronic medical record process (see FIG. 8) described later. The program area 121 also stores application programs such as an operating system (OS) and browser software.

An account management master D1 is stored in the master area 122. The account management master D1 is used for user authentication when logging in to the electronic medical chart system 1. The account management master D1 is appropriately edited and stored in the master area 122 according to a user operation of the electronic medical chart device 10 or the client terminal 20 at the time of initial setting or maintenance of the electronic medical chart device 10. ..

Here, FIG. 2 is an example of an account management screen P1 for editing the account management master D1. On the account management screen P1, it is possible to edit information regarding a user who uses the electronic medical chart system 1. In FIG. 2, Clark A is selected from a plurality of users registered in the account management master D1, and various information regarding Clark A can be edited. The “proxy input authority” shown in FIG. 2 is the authority of a proxy operation for acting a doctor's operation (input operation to an electronic medical chart). The target doctor who should act on his/her behalf can be selected from a drop-down list. In the example shown in FIG. 2, the clerk A is given the proxy input authority to perform the proxy operation of the doctor A. As a result, Clark A can describe the medical record information (for example, the medical record information B1 to B21 shown in FIG. 5) described later in the electronic medical record as a substitute of the doctor A (doctor office work assistant).

FIG. 3 shows an example of user data registered in the account management master D1. As shown in FIG. 3, information such as user ID, user name, password, proxy input authority, target doctor, and qualification is registered in the account management master D1 for each user. The user ID and the user name are examples of identification information for identifying the user. The password is used for user authentication when logging in to the electronic medical chart system 1. The qualification indicates the qualification held by the user. In the account management screen P1 shown in FIG. 2, the authority regarding the electronic medical record can be set individually for each qualification. For example, a doctor is given authority to refer to, modify, and save an electronic medical record, a nurse is given authority to refer to and modify an electronic medical chart, and a clerk is granted authority to refer to an electronic medical chart. .. However, the user having the proxy input authority is given the same authority as the target doctor regardless of the qualification of the user.

Although not shown, the master area 122 also stores other master information such as a disease name master, a patient master, and a drug master.

Information such as XML information D2 (see FIG. 6) and chart database D3 is stored in the data area 123. The XML information D2 is the description of the medical record information (that is, information indicating the content of medical treatment) written in the electronic medical record using XML (Extensible Markup Language). The XML information D2 is created in response to a user operation such as a doctor using the client terminal 20 and is updated at any time. The XML information D2 includes writer information described later (for example, writer information W1 to W21 shown in FIG. 7) in addition to the medical record information.

The medical record database D3 is a database for accumulating the medical record information described in the electronic medical record and storing it for a long term. For example, when a user such as a doctor who uses the client terminal 20 saves medical record information at the end of a medical examination, the medical record information and the described person information included in the XML information D2 are stored in the medical record database D3. Stored in.

One or more of the account management master D1, the XML information D2, and the medical chart database D3 may be stored in a storage device provided outside the electronic medical chart device 10. For example, the electronic medical record system 1 may include a server device that stores one or more of the account management master D1, the XML information D2, and the medical record database D3. The control unit 11 may be able to access the server device via the Internet or the like.

The display unit 13 is a display unit such as a liquid crystal display or an organic EL display that displays various kinds of information according to a control instruction from the control unit 11. The operation unit 14 is an operation unit operated by a user to input various kinds of information to the electronic medical chart device 10. Specifically, the operation unit 14 includes a keyboard and a mouse (pointing device) that accept input operations on various operation screens displayed on the display unit 13. Further, the operation unit 14 may include a touch panel that receives touch operations on various operation screens displayed on the display unit 13 or a voice input device that receives input of various information by voice recognition.

The communication IF 15 includes a network card or the like that performs wireless or wired data communication with an external device such as the client terminal 20 and the printer 30 via the network 40 according to a predetermined communication protocol. Interface.

The drive device 16 can read information such as the electronic medical record program from a computer-readable recording medium 161 recorded with the electronic medical record program. The recording medium 161 is a CD, a DVD, a BD, a USB memory, or the like, and the drive device 16 is a CD drive, a DVD drive, a BD drive, a USB port, or the like. Then, in the electronic medical chart device 10, the control unit 11 stores the electronic medical chart program read from the recording medium 161 by using the drive device 16 in the program area 121.

In the electronic medical chart apparatus 10 configured as described above, the control unit 11 includes the description processing unit 111, the acquisition processing unit 112, the storage processing unit 113, the display control unit 114, the update processing unit 115, and the print control unit. Includes 116. Specifically, the control unit 11 executes various processes according to the electronic medical chart program, so that in the electronic medical chart device 10, the control unit 11 causes the description processing unit 111, the acquisition processing unit 112, and the storage processing unit. 113, a display control unit 114, an update processing unit 115, and a print control unit 116.

The description processing unit 111 can sequentially describe a plurality of pieces of medical record information in an electronic medical record according to a user operation such as a doctor using the client terminal 20. The medical record information can be written in the electronic medical record, for example, through the medical record screen P2.

FIG. 4 is a diagram showing an example of a chart screen P2 displayed on the electronic chart device 10 or the client terminal 20. As shown in FIG. 4, the chart screen P2 includes display areas A1 to A5.

In the display area A1, electronic medical records created in the past can be displayed. In the display area A2, the electronic medical record that is the current editing target can be displayed. Patient information is displayed in the display area A3. A keypad used for editing the electronic medical record is displayed in the display area A4. Further, in the display area A5, shortcut keys and the like used for editing the electronic medical record are displayed.

Here, FIG. 5 shows an example of an electronic medical chart displayed in the display area A2 of the medical chart screen P2. In the electronic medical chart shown in FIG. 5, plural pieces of medical chart information B1 to B21 have been described.

In the electronic medical chart device 10, a plurality of methods are prepared as a method of writing the medical chart information in the electronic medical chart. For example, by selecting a desired area of the electronic medical record with a mouse or a touch panel and then inputting a character string from the keyboard, the medical record information can be written in the electronic medical record. The medical chart information can be written in the electronic medical chart by operating the keypad displayed in the display area A4 with a mouse, a ten-key pad, or a touch panel. It is also possible to register arbitrary chart information as set information in advance and select the set information with a mouse, a ten-key pad or a touch panel to describe the chart information in the electronic chart. Further, the medical record information can be written in the electronic medical chart by dragging and dropping an icon indicating the set information to a desired area of the electronic medical chart displayed in the display area A2.

It should be noted that a plurality of users may sequentially write the medical record information for the same electronic medical record (that is, the electronic medical record of the same patient on the same date). For example, after the doctor A writes the medical record information in the electronic medical record, the new medical record information can be sequentially added by the clerk A and the medical doctor B in the same electronic medical record.

By the way, in an electronic medical record, it is required that the responsibility of preparation is clarified, that is, it is clear from the viewpoint of a third party when and who created it. Therefore, in the electronic medical chart device, a user (for example, a doctor) who has finally saved the electronic medical chart and a storage date and time thereof are generally recorded. However, if only the user who finally saved the electronic medical record and the storage date and time are recorded, the medical record information can be recorded in the electronic medical record by a plurality of users (for example, doctors, clerks, nurses, associate nurses). When is written in sequence, I do not know which medical record information was entered by whom. On the other hand, in the electronic medical chart device 10 according to the present embodiment, by the configuration described below, it is possible to know when and who wrote the individual medical chart information described in the electronic medical chart.

Each time the description processing unit 111 writes the medical record information in the electronic medical record, the acquisition processing unit 112 describes the person who wrote the medical record information, and the date and time of the description of the medical record information. It is possible to acquire writer information including information and. The writer identification information is, for example, a user ID or a user name corresponding to the logged-in user. The acquisition processing unit 112 acquires the writer identification information from the account management master D1, for example. As the description date/time information, for example, the time synchronized between the electronic medical chart device 10 and the client terminal 20 can be used. Alternatively, the time (time stamp) acquired from any time server on the Internet may be used as the described date and time information.

When the medical record information is written in the electronic medical record by inputting a character string or a sentence from the keyboard, the character string or the sentence input from the keyboard is temporarily displayed in the text box, and then finally. When the confirmation button is operated, the medical record information is written in the electronic medical record. Then, the writer information corresponding to the medical record information is acquired by the acquisition processing unit 112. In this case, for example, the date and time when the confirm button is operated is acquired as the described date and time information.

Further, when the medical record information is described in the electronic medical record by selecting the set information, at the time when the set information is selected, the pre-registered medical record information corresponding to the set information is the Described in electronic medical records. Then, the writer information corresponding to the medical record information is acquired by the acquisition processing unit 112. In this case, for example, the date and time when the set information is selected is acquired as the described date and time information.

It should be noted that the acquisition processing unit 112, when the medical record information is described in the electronic medical record by the description processing unit 111 in response to a proxy operation by a second user acting on behalf of the first user, the first user is And the identification information of both the second user is acquired as the writer identification information. For example, when the medical record information is described in the electronic medical record by the description processing unit 111 according to the proxy operation by the above-mentioned Clark A (see FIGS. 2 and 3), the acquisition processing unit 112 determines that The identification information of the doctor A who is the target physician and the identification information of Clark A who is the agent are acquired as the writer identification information.

The storage processing unit 113 can store the describer information acquired by the acquisition processing unit 112 in the storage unit 12 in association with the medical record information. Specifically, the storage processing unit 113 associates the describer information acquired by the acquisition processing unit 112 with the medical record information each time the medical record information is described in the electronic medical record by the description processing unit 111. Then, the XML information D2 is stored in the storage unit 12.

FIG. 6 shows a part of the XML information D2 stored in the storage unit 12 by the storage processing unit 113. As shown in FIG. 6, in the XML information D2, the writer information W11 is stored in association with the medical record information B11, and the writer information W12 is stored in association with the medical record information B12.

In the writer information W11 shown in FIG. 6, the user ID of the writer of the chart information B11 is “002”, the user name of the writer of the chart information B11 is “doctor A”, and the chart information It indicates that the date and time described in the information B11 is 19:42:12 on July 6, 2016. In addition, since the values of “ProxyUserID” and “ProxyUserName” are empty, the person who has written information W11 indicates that the medical record information B11 is not written by a proxy operation.

In the writer information W12 shown in FIG. 6, the user ID of the writer of the chart information B12 is “005”, the user name of the writer of the chart information B12 is “Clark A”, and the chart information The information B12 is described by the proxy operation, the user ID and the user name of the target doctor are "002" and "doctor A", and the date and time of the record information B12 is July 6, 2016. It is 19:45:27".

The display control unit 114 can cause the display unit 13 or the display unit 23 to display the writer information associated with the medical record information together with the plurality of medical record information described in the electronic medical record. For example, the display control unit 114 may display the writer information associated with the medical record information adjacent to the medical record information. The display control unit 114 displays the chart information and the writer information based on the chart information included in the XML information D2 and the writer information corresponding to the chart information. It is displayed on the display unit 23.

Here, FIG. 7 shows an example of an electronic medical record displayed in the display area A2 by the display control unit 114. In the example shown in FIG. 7, corresponding writer information W1 to W21 is displayed adjacent to each other at the bottom of each of the medical record information B1 to B21. This makes it easy to understand when/who wrote each piece of medical record information.

When the writer information includes the identification information of the target doctor as the writer information W12 shown in FIG. 6, the display control unit 114 causes the writer information W12 shown in FIG. 7, for example. As described above, the writer information is displayed so that both the agent and the target doctor can be recognized. In the writer information W12 shown in FIG. 7, “Doctor A (provision: Clark A)” is displayed, and it is clearly indicated that Clark A described the chart information B12 as the agent of the doctor A.

Note that, for some reason such as a difference in version of the electronic medical record program, if the medical record information is not associated with the medical record information, the display control unit 114 causes the medical record information W15 shown in FIG. 7, for example. As described above, it may be displayed that the writer information is not associated.

The display control unit 114 can display the medical chart information in a display mode selected at any time from a plurality of display modes including a first display mode and a second display mode in accordance with a user operation. Is. The first display mode is a display mode in which only the medical record information of the medical record information and the writer information is displayed on the display unit 13 or the display unit 23, as in the display example shown in FIG. 5 , for example. .. The second display mode is a display mode in which both the medical record information and the writer information are displayed on the display unit 13 or the display unit 23, as in the display example shown in FIG. 7 , for example.

The display control unit 114 can switch the display mode according to a predetermined display mode switching operation by the user. For example, the display control unit 114 may sequentially switch the display mode each time the header area in the display area A2 (the area currently displayed as “current medical record” in FIG. 5 ) is left-clicked with the mouse. Good. As a result, the user can immediately switch to the desired display mode with a simple operation.

In the second display mode, the display control unit 114 may display the writer information in a display mode different from that of the medical record information. For example, the chart information may be displayed in a relatively conspicuous color (for example, a dark color such as black), and the author information may be displayed in a relatively inconspicuous color (for example, a light color such as gray). .. Alternatively, the chart information may be displayed in relatively large characters, and the writer information may be displayed in relatively small characters. Thereby, in the second display mode, it is possible to easily distinguish the medical record information and the writer information, and thus the visibility of the medical record information is reduced due to the display of the writer information, and It is possible to prevent the medical record information from being overlooked.

The display control unit 114 may display only one of the writer identification information and the description date/time information included in the writer information in the second display mode. Alternatively, the display control unit 114 displays a display mode for displaying both the writer identification information and the description date/time information included in the writer information, and the description of the writer identification information and the description date/time information. The display mode in which only the person identification information is displayed and the display mode in which only the described date and time information of the described person identification information and the described date and time information may be sequentially switched according to a user operation.

The update processing unit 115 can update the medical record information described in the electronic medical record according to a user operation. For example, when any of the medical record information displayed in the display area A2 is selected as an update target by, for example, a double-click operation of a mouse, a text box displaying the medical record information is displayed and a keyboard is displayed. It becomes possible to change the medical record information. After that, when the finalize button is finally operated, the medical record information is updated.

When the medical record information is updated by the update processing unit 115, the acquisition processing unit 112 acquires the identification information of the updater of the medical record information and the update date and time of the medical record information as the writer identification information. For example, the date and time when the confirm button is operated is acquired as the described date and time information. The writer information acquired by the acquisition processing unit 112 is stored in the storage unit 12 by the storage processing unit 113 in association with the medical record information. At this time, the writer information corresponding to the medical record information before updating may be overwritten by the writer information corresponding to the medical record information after updating, or may be retained without being overwritten. The display control unit 114 causes the display unit 13 or the display unit 23 to display, together with the medical record information, the latest writer information associated with the medical record information.

The print control unit 116 can cause the printer 30 to print the writer information associated with the medical record information together with the medical record information described in the electronic medical record. The printer 30 is an example of the “printing unit” in the present invention.

The print control unit 116 causes the printer 30 to print the medical chart information in a print mode selected according to a user operation from a plurality of print modes including a first print mode and a second print mode. Is possible. The first print mode is a print mode that causes the printer 30 to print only the medical record information of the medical record information and the writer information. That is, the first print mode is a print mode corresponding to the first display mode. The second print mode is a print mode that causes the printer 30 to print both the medical record information and the writer information. That is, the second print mode is a print mode corresponding to the second display mode.

As a method of selecting the print mode, for example, a method of presetting one of the first print mode and the second print mode from a setting screen or the like can be considered. Alternatively, when a user performs a predetermined print operation, a dialog box in which the print mode can be selected may be displayed. Furthermore, according to the display mode (the first display mode or the second display mode) at the time when the print operation is performed, the print mode (the first print mode or the second print mode) corresponding to the display mode is performed. The print mode) may be automatically selected.

In addition, in the present embodiment, the medical record information is stored as the XML information D2 in a state in which it is collected for each predefined block.

For example, regarding the medical record information regarding the inspection result (hereinafter, referred to as “inspection result information”), a plurality of inspection result information having the same inspection date are collected in one block and stored as the XML information D2. Specifically, the in XML information D2, a plurality of test result information examination date is common is inserted between the shown to open Hajimeta grayed and end tag that is a block relating to test results. Therefore, in a state where the inspection result information on a certain inspection day (hereinafter, referred to as “first inspection result information”) is already stored as the XML information D2, new inspection result information on the same inspection day (hereinafter, When the “second inspection result information” is stored, these two inspection result information are collected into one block and stored as the XML information D2. As a result, these two pieces of inspection result information are displayed as one block in the display area A2. In the present embodiment, the storage processing unit 113 stores the writer information acquired by the acquisition processing unit 112 in the storage unit 12 for each block. Therefore, the block in which the first inspection result information and the second inspection result information are collected is associated with the writer who indicates the writer and the description date and time of the second inspection result information. As a result, in the second display mode, the writer information of the first inspection result information is not displayed, but the writer information of the second inspection result information is displayed.

Further, for example, regarding medical chart information regarding medication (hereinafter referred to as “medication information”), a plurality of medication information having a common usage and the number of administration days are collected in one block and stored in the XML information D2. Therefore, while the dosage information of the usage and the administration days (hereinafter, referred to as “first dosage information”) is already stored as the XML information D2, new dosage information of the same usage and the administration days (hereinafter, “ (Hereinafter referred to as “second medication information”) is stored, these two medication information are combined into one block and stored as the XML information D2. As a result, these two medication information are displayed as one block in the display area A2. Then, in the second display mode, the writer information of the first medication information is not displayed, but the writer information of the second medication information is displayed.

As described above, in the present embodiment, when a plurality of pieces of medical record information are collected in one block, all the writer information corresponding to the plurality of pieces of medical record information is not stored, but the medical record with the latest description date and time is not stored. Only information is stored. Therefore, an increase in the file size of the XML information D2 due to the storage of all the writer information corresponding to the plurality of medical record information is suppressed. In addition, as another embodiment, when a plurality of pieces of medical record information are collected in one block, all the writer information corresponding to the plurality of pieces of medical record information may be stored.

In addition, in the present embodiment, when a plurality of pieces of medical record information are collected in one block, not all the writer information corresponding to the plurality of pieces of medical record information is displayed, but only the medical record information with the latest description date and time. Is displayed. Therefore, the deterioration of the visibility of the medical record information due to the display of all the writer information corresponding to the plurality of medical record information in the second display mode is suppressed. In addition, as another embodiment, when a plurality of pieces of medical chart information are collected in one block, all the writer information corresponding to the plurality of pieces of medical chart information may be displayed.

Note that a plurality of pieces of medical record information is “collected and stored in one block” does not necessarily mean that the plurality of pieces of medical record information are stored adjacently or in close proximity to each other, and the control unit 11 causes the plurality of pieces of medical record information to be stored. It suffices to be stored in a recognizable state as one block. For example, the plurality of pieces of medical record information may be stored in association with each other.

The definition of the block (that is, the condition for grouping a plurality of chart information items) may be changed, added, or deleted according to a user operation. Further, the block may be divided into a plurality of blocks according to a user operation. Further, a plurality of blocks may be combined into one block according to a user operation. For example, if the cursor moves to another area while the user is performing an input operation on an input area where arbitrary information can be input, if another item is selected, or a line break occurs. It is conceivable that each time the delimiter operation is performed, such as when the Tab key is operated, the writer information is acquired and stored in association with each other. In this case, after that, when the cursor is returned to the input area and the input is continued, when the line feed is deleted and the input is continued, the space input by the operation of the Tab key is deleted and the input is performed. If the continuation is continued, the input contents up to that point are combined as one block at the time when the delimiter operation is performed thereafter, and the writer information corresponding to the block is acquired and stored in association with It is possible. In addition, when a plurality of medication information having a common usage and the same number of administration days are regarded as one prescription order, a group of a plurality of prescription orders may be included in the definition of the block. For example, when the information on the first prescription order such as the usage and the number of administration days for the drug A is input, the writer information corresponding to the information on the first prescription order is acquired, and thereafter, the drug A for the drug B is acquired. When the information of the second prescription order having the same usage and the same number of days as the administration is input, the group of the first prescription order and the second prescription order is determined as one block, and the writer corresponding to the block. It is conceivable that the information is acquired and stored in association with the block.

[Client terminal 20]
On the other hand, as shown in FIG. 1, the client terminal 20 is a computer including a control unit 21, a storage unit 22, a display unit 23, an operation unit 24, a communication IF 25, a drive device 26, and the like. The client terminal 20 is provided in a clinic of a hospital, a dispensing room where dispensing is performed, a ward in which a patient is hospitalized, an accounting window, and the like, and is used by medical staff such as doctors, pharmacists, nurses, and clerks. It is an operation terminal.

The control unit 21 has control devices such as a CPU, a ROM, a RAM, and an EEPROM. The CPU is a processor that executes various arithmetic processes. The ROM is a non-volatile storage unit in which information such as a control program for causing the CPU to execute various processes is stored in advance. The RAM is a volatile storage unit, and the EEPROM is a non-volatile storage unit. The RAM and the EEPROM are used as a temporary storage memory (work area) for various processes executed by the CPU. Then, the control unit 21 uses the CPU to execute various processes according to various control programs stored in the ROM, the EEPROM, or the storage unit 22 in advance.

The storage unit 22 is a non-volatile storage unit such as a hard disk, an SSD, or a flash memory in which various control programs executed by the control unit 21 and various data are stored. Specifically, the storage unit 22 stores an operating system (OS) and application programs such as browser software. The browser software causes the display unit 23 to display various operation screens and the like by accessing the electronic medical chart device 10 via the network 40, and also allows input operation using the operation unit 24 on the operation screen. It is application software for transmitting to the electronic medical chart device 10. Specifically, when the address information such as a URL (Universal Resource Locator) corresponding to the electronic medical record apparatus 10 is input to a predetermined position of the operation screen displayed by the browser software, the control unit 21 The electronic medical chart device 10 is accessed based on the address information.

The display unit 23 is a display unit such as a liquid crystal display or an organic EL display that displays various kinds of information according to a control instruction from the control unit 21. The operation unit 24 is an operation unit operated by a user to input various information to the client terminal 20. Specifically, the operation unit 24 includes a keyboard and a mouse (pointing device) that accept input operations on various operation screens displayed on the display unit 23. The operation unit 24 may include a touch panel that receives touch operations on various operation screens displayed on the display unit 23, or a voice input device that receives input of various information by voice recognition.

The communication IF 25 is a communication interface including a network card or the like that executes data communication wirelessly or by wire according to a predetermined communication protocol with an external device such as the electronic medical chart device 10 via the network 40. ..

The drive device 26 can read information such as the OS or the browser software from a computer-readable recording medium 261 in which the OS or the browser software is recorded. The recording medium 261 is a CD, a DVD, a BD, a USB memory, or the like, and the drive device 26 is a CD drive, a DVD drive, a BD drive, a USB port, or the like.

In the electronic medical chart system 1, the electronic medical chart apparatus 10 and the client terminal 20 constitute a server client system, and the electronic medical chart apparatus 10 displays and records various information according to a user operation of the client terminal 20. And processing such as printing. That is, the display, operation, selection, and input described below are performed by the display unit 13, the operation unit 14 of the electronic medical chart apparatus 10, the display unit 23, the operation unit 24, or the like of the client terminal 20. Is done using.

[Electronic chart processing]
FIG. 8 is a flowchart showing an example of the procedure of the electronic medical chart process executed by the control unit 11. The electronic medical record processing is started in response to the execution of the electronic medical record program in the electronic medical record apparatus 10.

<Step S11>
In step S11, the control unit 11 performs a login process. Specifically, the control unit 11 displays a login screen for inputting a user name and a password in response to a login operation (for example, operation of a login button) by the user. Then, the control unit 11 performs user authentication by collating the input user name and password with the user information registered in the account management master D1.

<Step S12>
In step S12, the control unit 11 displays the chart screen P2 in response to a user operation. For example, the control unit 11 displays the chart screen P2 corresponding to the electronic chart of the patient in response to the selection of any patient from the patients listed on the consultation list screen (not shown). indicate.

<Step S13>
In step S13, the control unit 11 (the description processing unit 111) determines whether or not a description operation for describing new medical record information in the electronic medical record has been performed. When it is determined that the writing operation has been performed (S13: Yes), the control unit 11 shifts the process to step S14, and when it is determined that the writing operation has not been performed (S13: No). ), the process proceeds to step S16. The described operation is, for example, a character string input operation using a keyboard, an input operation using the keypad, the drag and drop operation using a mouse, or the like.

<Step S14>
In step S14, the control unit 11 (the acquisition processing unit 112) has the writer information corresponding to the medical record information newly described in the electronic medical record (that is, the writer identification information and the description date/time information). To get Specifically, the control unit 11 acquires the user ID and the user name of the logged-in user as the describer identification information, and also acquires the current time as the description date and time information.

<Step S15>
In step S15, the control unit 11 (the storage processing unit 113) stores the writer information acquired in step S14 in the storage unit 12 in association with the medical record information newly described in the electronic medical record. To do. Specifically, the control unit 11 stores the writer information and the medical record information in the storage unit 12 as the XML information D2. Then, the control unit 11 shifts the processing to step S16.

<Step S16>
In step S16, the control unit 11 (the update processing unit 115) determines whether or not an update operation for updating the medical record information described in the electronic medical record has been performed. When it is determined that the update operation has been performed (S16: Yes), the control unit 11 shifts the processing to step S17, and when it is determined that the update operation has not been performed (S16: No). ), the process proceeds to step S19. The update operation is, for example, the double click operation with a mouse.

<Step S17>
In step S17, the control unit 11 (the acquisition processing unit 112) acquires the writer information (that is, the writer identification information and the description date/time information) corresponding to the updated medical record information. Specifically, the control unit 11 acquires the user ID and the user name of the logged-in user as the describer identification information, and also acquires the current time as the description date and time information.

<Step S18>
In step S18, the control unit 11 (the storage processing unit 113) stores the writer information acquired in step S17 in the storage unit 12 in association with the updated medical record information. Specifically, the control unit 11 stores the writer information and the medical record information in the storage unit 12 as the XML information D2. Then, the control unit 11 shifts the processing to step S19.

<Step S19>
In step S19, the control unit 11 (display control unit 114) determines whether or not a display mode switching operation requesting switching of the display mode has been performed. Then, if it is determined that the display mode switching operation has been performed (S19: Yes), the control unit 11 shifts the processing to step S20, and determines that the display mode switching operation has not been performed. (S19: No), the process proceeds to step S21. The display mode switching operation is, for example, a left click operation of the mouse in the header area.

<Step S20>
In step S20, the control unit 11 (display control unit 114) switches the display mode. For example, when the current display mode is the first display mode, the control unit 11 switches to the second display mode. As a result, the writer information corresponding to the medical record information is displayed on the medical record screen P2. In addition, when the current display mode is the second display mode, the control unit 11 switches to the first display mode. As a result, the writer information corresponding to the medical record information is hidden on the medical record screen P2. Then, the control unit 11 shifts the processing to step S21.

<Step S21>
In step S21, the control unit 11 (print control unit 116) determines whether or not a print operation requesting printing of the medical record information has been performed. Then, when it is determined that the print operation is performed (S21: Yes), the control unit 11 shifts the process to step S22, and when it is determined that the print operation is not performed (S21: No). ), the process proceeds to step S23. The print operation is, for example, a print button operation.

<Step S22>
In step S22, the control unit 11 (print control unit 116) causes the printer 30 to print the medical record information. Specifically, the control unit 11 generates print data including the medical record information, transmits the print data to the printer 30, and causes the printer 30 to print the medical record information. Here, when the user selects the second print mode, the control unit 11 causes the printer 30 to print the writer information together with the medical record information. On the other hand, when the user selects the first print mode, the control unit 11 causes the printer 30 to print only the chart information. Then, the control unit 11 shifts the processing to step S23.

<Step S23>
In step S23, the control unit 11 determines whether or not a saving operation requesting saving of the medical record information has been performed. When it is determined that the save operation has been performed (S23: Yes), the control unit 11 shifts the processing to step S24, and when it is determined that the save operation has not been performed (S23: No). ), the process proceeds to step S25. The save operation is, for example, an operation of a save button.

<Step S24>
In step S24, the control unit 11 stores the medical record information in the medical record database D3. Specifically, the control unit 11 registers, in the medical chart database D3, the medical chart information included in the XML information D2 and the writer information associated with the medical chart information. Then, the control unit 11 shifts the processing to step S25.

<Step S25>
In step S25, the control unit 11 determines whether or not the user has performed a logout operation (for example, operation of a logout button). When it is determined that the logout operation has been performed (S25: Yes), the control unit 11 returns the process to step S11, and when it is determined that the logout operation has not been performed (S25: No). ), the process returns to step S13.

As described above, in the electronic medical chart device 10, the electronic medical chart process is executed by the control unit 11, so that the writer information is acquired every time the medical chart information is recorded in the electronic medical chart. The writer information is stored in the storage unit 12 in association with the medical record information. Therefore, it becomes possible to know when/who wrote the individual medical record information described in the electronic medical record.

Further, in the electronic medical chart device 10, the writer information is displayed on the medical chart screen P2 displayed when the medical chart information is written in the electronic medical chart. Therefore, for example, even if a doctor notices that wrong electronic chart information is written by another user on the electronic medical chart while writing the medical chart information, who describes the medical chart information? You can tell right away what you did.

In addition, the electronic medical chart device 10 can arbitrarily switch between the first display mode in which the writer information is not displayed and the second display mode in which the writer information is displayed. Therefore, for example, basically, the first display mode is used, and the display mode is arbitrarily switched to the second display mode only during the confirmation work before the saving operation is performed. Can be switched.

Further, in the electronic medical chart device 10, when the medical chart information is written by a proxy, the identification information of the proxy and the identification information of the target doctor are acquired and stored in association with the medical chart information. Therefore, even if the medical chart information is written by the agent, it becomes possible to know who is the doctor who has caused the agent to write the medical chart information.

In the present embodiment, the electronic medical chart apparatus 10 and the client terminal 20 constitute a server client system, and the electronic medical chart program is executed in the electronic medical chart apparatus 10, but the present invention is not limited to this. In another embodiment, the electronic medical record program may be executed in any of the client terminals 20. In this case, the electronic medical chart device 10 may function as a mere data server. In still another embodiment, the electronic medical record system 1 may be configured only with a stand-alone type information processing device that executes the electronic medical record program.

Further, in the present embodiment, the medical record information and the writer information that are temporarily stored as the XML information D2 are finally stored in the medical record database D3, but the present invention is not limited to this. In another embodiment, for example, the medical record information and the writer information may be stored as the XML information D2 for a long term. Alternatively, the control unit 11 may store the medical record information and the writer information corresponding to the medical record information in the medical record database D3 whenever the medical record information is written in the electronic medical record.

Further, in the present embodiment, one target doctor is registered in advance for one agent, but the present invention is not limited to this. In another embodiment, for example, a plurality of target doctors may be registered in advance for one agent. In this case, the control unit 11 may cause the proxy to select one target doctor from the plurality of target doctors on the login screen displayed when the proxy logs in.

Further, in the present embodiment, in the display area A2 of the medical record screen P2, the writer information regarding the electronic medical record that is the current editing target is displayed, but the present invention is not limited to this. In another embodiment, the control unit 11 may display the writer information regarding electronic medical records created in the past, for example, in the display area A1 of the medical record screen P2.

Further, in the present embodiment, in the second display mode, the medical record information and the writer information corresponding to the medical record information are displayed adjacent to each other, but the present invention is not limited to this. In another embodiment, for example, when the pointer is moved on the medical record information, the control unit 11 may popup-display the writer information corresponding to the medical record information.

Further, in the present embodiment, in the second display mode, the plurality of writer information items are displayed in the same display mode (for example, all gray), but the present invention is not limited to this. In another embodiment, the control unit 11 may display the writer information in different display modes (for example, different colors) for each writer. In still another embodiment, the control unit 11 corresponds to the display mode of the writer information corresponding to the medical record information described by the currently logged-in user and the medical record information described by another user. The display mode of the writer information may be set to a different display mode. For example, the control unit 11 may set the latter display mode to a display mode more conspicuous than the former display mode.

Further, in the present embodiment, the writer information corresponding to all the medical record information displayed in the display area A2 is displayed in the second display mode, but the present invention is not limited to this. In another embodiment, the control unit 11 may display only the author information corresponding to a part of the medical record information displayed in the display area A2. For example, the control unit 11 displays only the writer information corresponding to the medical record information described by a user other than the currently logged-in user among the medical record information displayed in the display area A2. Good.

1: Electronic chart system 10: Electronic chart device 11: Control section 12: Storage section 13: Display section 14: Operation section 15: Communication IF
16: drive device 20: client terminal 21: control unit 22: storage unit 23: display unit 24: operation unit 25: communication IF
26: Drive device 30: Printer 40: Network B1 to B21: Chart information W1 to W21: Describer information

Claims (13)

A description processing unit that records medical record information in an electronic medical record according to user operation,
The writer information including the writer identification information indicating the writer of the new medical record information added to the same electronic medical record by the description processing unit and the description date/time information indicating the description date/time of the medical record information is added to the new medical record. A storage processing unit that stores the storage unit in association with the information;
Every time the new medical record information is added by the description processing unit, an acquisition processing unit that acquires the description date/time information indicating the description date/time of the new medical record information,
With a plurality of the medical record information described in the electronic medical record, a display control unit that causes the display unit to display the writer information associated with the medical record information,
Equipped with
The display control unit displays a first display mode for displaying only the medical record information on the display unit out of the medical record information and the writer information and a second display mode for displaying both the medical record information and the writer information on the display unit. Switching between the two display modes in accordance with the operation of a specific area on the screen displayed on the display unit in the first display mode and the second display mode,
The description processing unit describes medical record information in the electronic medical record in accordance with the user operation on at least the screen displayed on the display unit in the first display mode,
Electronic medical record system. The acquisition processing unit, each time the new medical record information is added by the description processing unit, the writer identification information indicating the writer of the new medical record information and the description date and time of the new medical record information. Acquiring the describer information including the description date and time information,
The electronic medical record system according to claim 1 . The display control unit displays the writer information associated with the medical record information adjacent to the medical record information,
The electronic medical record system according to claim 1 . Further comprising an update processing unit for updating the medical record information described in the electronic medical record according to a user operation,
The acquisition processing unit, when the medical record information is updated by the update processing unit, acquires the identification information of the updater of the medical record information and the update date and time of the medical record information as the writer information,
The display control unit causes the display unit to display the latest reporter information associated with the medical record information together with the medical record information,
The electronic medical record system according to claim 2 . The description processing unit describes the medical record information in the electronic medical record by the description processing unit according to a proxy operation by a second user who is given the same authority as the first user and performs the operation of the first user .
The acquisition processing unit associates the identification information of the first user with the identification information of the second user when the medical chart information is described in the electronic medical chart in response to the proxy operation by the second user. Based on the management information, the identification information of both the first user and the second user is acquired as the writer identification information.
The electronic medical record system according to claim 2 . Along with the medical record information described in the electronic medical record, a print control unit that causes the printing unit to print the describer information associated with the medical record information is further provided.
Electronic medical record system according to any one of claims 1 to 5. The print control unit causes the printing unit to print both the medical record information and the writer information in a first print mode in which only the medical record information of the medical record information and the writer information is printed in the printing unit. Causing the print unit to print the medical record information in a print mode selected according to a user operation from a plurality of print modes including a second print mode,
The electronic medical record system according to claim 6 . The acquisition processing unit acquires the describer information for each one or a plurality of prescription orders,
The storage processing unit stores the writer information acquired by the acquisition processing unit in the storage unit for each of the one or more prescription orders.
The electronic medical record system according to claim 2 . The acquisition processing unit acquires the writer information each time a delimitation operation is performed in the middle of the input operation of the medical record information,
The storage processing unit stores the describer information acquired by the acquisition processing unit in the storage unit for each chart information divided by the division operation.
The electronic medical record system according to claim 2 . The storage processing unit stores the writer information in the storage unit in association with medical record information in a predefined block unit including the new medical record information.
Electronic medical record system according to any one of claims 1 to 9. The storage processing unit stores the writer information in the storage unit for each medical record information regarding a plurality of inspection results having a common inspection date.
Electronic medical record system of claim 1 0. The storage processing unit stores the describer information in the storage unit for each medical record information regarding a plurality of medications having a common usage and the number of administration days.
Electronic medical record system of claim 1 0. A description processing step of recording medical record information in an electronic medical record according to a user operation,
The writer information including the writer identification information indicating the writer of the new medical record information added to the same electronic medical record in the description processing step and the description date/time information indicating the description date/time of the medical record information is added to the new medical record. A storage processing step of storing the storage unit in association with the information;
Every time the new medical record information is added by the description processing step, an acquisition step of acquiring the description date/time information indicating the description date/time of the new medical record information,
With a plurality of the medical record information described in the electronic medical record, a display step of displaying the writer information associated with the medical record information on a display unit,
An electronic medical record program to be executed by the processor to,
In the displaying step, a first display mode in which only the medical record information out of the medical record information and the describer information is displayed on the display unit and a second display mode in which both the medical record information and the describer information are displayed on the display unit The display mode is switched in accordance with an operation of a specific area on the screen displayed on the display unit in the first display mode and the second display mode,
In the description processing step, medical record information is described in the electronic medical record according to the user operation on the screen displayed on the display unit in at least the first display mode,
Electronic medical record program.

Images