JP6857302B2 - Electronic medical record - Google Patents

Description

The present invention relates to an electronic medical record, and more particularly to an electronic medical record capable of inputting with the same feeling as a paper electronic medical record.

The electronic medical record replaces the paper medical record that doctors and dentists have conventionally recorded the progress of medical treatment, and stores and manages the information recorded in the medical record as electronic information.
Currently, there are roughly two types of electronic medical records in use.

One is to input necessary information by writing using an electronic pen input device. There is an advantage that doctors who are accustomed to paper medical records do not need to be proficient and can input with the same feeling as paper medical records.
On the other hand, since the information is recorded as image information, there is a disadvantage that it is difficult to utilize and organize the recorded information such as retrieval.

Another type of electronic medical record is to input necessary information by using a character input device such as a keyboard or a pointing device such as a mouse. For example, for items such as medical records, characters are input using a keyboard or the like. Then, regarding the disease name, medical practice, prescription, etc., another input screen (input sheet) is opened, the candidates to be input are searched, and the selection items such as the disease name selected from the search results are recorded (for example, patent documents). 1, in particular, paragraph 0011, FIG. 3 etc.).

Japanese Patent Application Laid-Open No. 2000-36004

The electronic medical record disclosed in Patent Document 1 has a great advantage that the recorded information can be easily utilized and managed because the information is recorded as text information instead of image information. Moreover, since the input items such as the disease name can be searched, the appropriate input items can be selected, and even if the input items are forgotten, the appropriate input items can be input.

However, since a separate sheet is opened for input, there is a problem that it is more difficult to use than a paper chart. This is because electronic medical records are unique compared to other cases where various information is recorded. For example, in the case of recording accounting information such as sales, the information recorded on the slip or the like may be mechanically input. On the other hand, in electronic medical records, it is necessary to input information with advanced judgment based on the expertise and experience of doctors and the like. For example, based on the information obtained from the interview from the patient, select the test that is considered necessary, or from the test results, reconsider that the information obtained from the interview that was neglected was important, and record the medical treatment. It may be rewritten. In this way, instead of mechanically inputting the information to be input in order, it is necessary to input while making various judgments, so the order of the input items becomes random or the information once input is rewritten. It is necessary to do so, and a flexible input system with few restrictions is desirable.
In a system such as the electronic medical record disclosed in Patent Document 1 in which a separate sheet is opened for each input item and input is performed, it is difficult to input across the input items. Since it is necessary to input another item after completely inputting one input item, the input procedure is restricted. In addition, since another sheet is opened, it is hidden behind another sheet and other input items cannot be seen, which causes a big problem that the information for making a necessary judgment cannot be understood.

Further, in the case of recording accounting information such as sales, it is possible to concentrate only the input work after the work is completed. On the other hand, since doctors and the like input electronic medical records while conducting interviews and treatments, a system that makes it easier to input is desired.

The present invention has been made to solve various problems as described above, and provides an electronic medical record that can be input with the same feeling as a paper medical record.

The electronic medical record according to the present invention is a browser that acquires information to be displayed by communicating with a server via a two-way communication line.
Multiple input items to be described in the paper chart are input to one sheet displayed by the above browser, and the input items are input.
Of the above multiple input items, corresponding to each of the selectable input items that can be selected from the predetermined options,
When the input start button arranged near the display position of the corresponding selection input item is selected, the option display means for displaying the options and the option display means.
It has a selection means for selecting an option to be input from the option display means.
The option display means opens a module that displays a plurality of options near the display position of the selection input item, and opens the module.
The selection means is characterized in that the module for displaying the plurality of options is closed, and the options selected from the plurality of options are displayed in the vicinity of the display position of the selection input item.

Further, in the electronic medical record according to the present invention, among the selection input items that can be selected from the above-mentioned predetermined options, the selection input items having a wide variety of options are the same.
Has more search means to search for choices,
The search means opens a search word input module near the display position of the corresponding selection input item when the input start button arranged near the display position of the corresponding selection input item is selected.
The character information input to the search word input module and the selection input item are transmitted to the server via the two-way communication line.
Information about a plurality of options determined by the server based on the character information and the selection input items is transmitted to the browser via the two-way communication line.
The option display means opens a module for displaying a plurality of options in the vicinity of the display position of the selection input item based on the information regarding the plurality of options, and opens a module for displaying the plurality of options.
The selection means is characterized in that the search word input module and the module for displaying the plurality of options are closed, and the option selected from the plurality of options is displayed in the vicinity of the display position of the selection input item.

Further, the search word input module and the module for displaying the plurality of options are characterized in that they have the minimum necessary size.

Since the electronic medical record according to the present invention is configured as described above, it has many features shown below.
First, since it is possible to input with the same feeling as an electronic medical record on paper, it does not require a proficiency period and can be used intuitively. Therefore, it can be easily used not only by doctors who are resident in hospitals, but also by doctors who work once a week.

Secondly, since another sheet does not open, it is easy to input in a random order or rewrite the information once input regardless of the order of the input items.
In addition, since other entered items are not hidden behind another sheet, the general items described in the electronic medical record are always recognizable, and necessary decisions can be made based on the general items described in the electronic medical record. it can.
Furthermore, since input and display are always performed at a nearby position in the sheet, input and confirmation after input can be performed without jumping the line of sight. In particular, since the medical record is usually input while performing medical treatment such as interview and palpation, or treatment, the line of sight goes back and forth between the medical record and the patient. Therefore, if the position of the input or the display is changed while facing the patient, a problem such as visual confusion is likely to occur, but such a problem does not occur in the electronic medical record of the present invention.

Third, because it is a web browser, it can be used immediately without installing an application. In addition, it is possible to immediately respond to various frequently occurring revisions such as examinations, disease names, drug additions and deletions, and reward revisions. That is, it does not require application updates as it does for applications.

Fourth, rewriting the sheet that becomes the medical record is performed at high speed because it is limited to limited modules such as a search word input module and a module that displays multiple options, and limited display data such as selected options. Is possible. In addition, communication with the server is limited to the transmission of search words and the reception of corresponding options, and since both are character information, it is possible to minimize the frequency of transmission and reception and the amount of data to be transmitted and received. .. Therefore, operations such as sheet rewriting can be executed at high speed, and can be used even when the communication environment is unstable.
Since it has such features, the input work can be performed quickly without feeling stress in the input. And since rewriting and the like are performed at high speed, the thinking of doctors and the like is not interrupted, and the judgment is not adversely affected.
It is also possible to input to the medical record by using a mobile device connected by an unstable line such as a wireless LAN at the time of rounds to the hospital room.

It is an image diagram of the input sheet of the electronic medical record which concerns on this invention. It is an image diagram of the input sheet of the electronic medical record which concerns on this invention, and is the figure which shows the sheet at the time of selecting an input item. It is an image diagram of the input sheet of the electronic medical record which concerns on this invention, and is the figure which shows the sheet at the time of selecting an option. It is an image diagram of the input sheet of the electronic medical record which concerns on this invention, and is the figure which shows the sheet when the selected option is displayed. It is a functional block diagram at the time of selecting the input item of the electronic medical record which concerns on this invention. It is a flow chart at the time of selecting the input item of the electronic medical record which concerns on this invention. It is a partial image diagram of the input sheet of the electronic medical record which concerns on this invention, and is the figure which shows the module used when selecting a plurality of options.

The configuration of the electronic medical record and the method of using the electronic medical record according to the present invention will be described below with reference to the drawings. The following description discloses a good example of the present invention, and the present invention is not limited to the embodiment.

Embodiment <Overall configuration of the system>
The electronic medical record according to the present invention is a browser that acquires information to be displayed by communicating with a server via a two-way communication line such as the Internet, and when using the Internet as a two-way communication line, it is a web browser. is there.
The terminal for using the electronic medical record may be a PC or a mobile terminal such as a smartphone or a tablet PC. It suffices if it is connected to a two-way communication line by wire or wireless. It is desirable that the communication environment is good, but it can be used even in an unstable communication environment.

The server may be, for example, a local server installed in a hospital, but preferably a server managed by an electronic medical record provider or the like. That is, a centralized server or the like managed by an electronic medical record provider or the like is preferable.
Many of the medical record input items are selected from the predetermined options. For example, items to be entered in items such as disease name, medical examination, examination, prescription, and injection are selected from predetermined options. These options are not always constant and are added or removed on a regular, irregular, and frequent basis. A server managed by an electronic medical record provider or the like is desirable as an electronic medical record server because it is easy to immediately reflect the revision of these options.

<Electronic medical record input sheet>
Next, the input sheet of the electronic medical record according to the present invention will be described with reference to FIGS. 1 to 4. FIG. 1 is an image diagram of an input sheet for an electronic medical record. The electronic medical record 1 is composed of a plurality of input items 2 such as a medical record, a disease name, and a medical practice. A plurality of items to be described in the paper chart are input to one sheet displayed by the above browser. The display position of each input item 2 corresponds to the display position of each item in the paper chart. This is to make it easier for doctors who are accustomed to using paper charts to become familiar with it.
There are a plurality of input items 2 such as medical records, disease names, medical practices, etc., but in FIG. 1, the symbol “2” is added only to the “disease name” in order to avoid complicating the figure. The same applies to the input start button described below, and the same applies to FIG. 2 and below.

The text input field 3 of the medical record is a field in which the contents of medical treatment performed by a doctor or the like can be entered by text input.
Regarding input item 2 such as disease name, medical practice, examination, image, prescription, injection, and own expense, it is a selectable input item that can be selected from predetermined options, and an appropriate option is selected from the options presented by this electronic medical record system. You can choose.

There are two types of selection input items, and since there are not many options for images, injections, and own expenses, a plurality of options are suddenly displayed. For example, if you want to input about injection, select the input start button 4 described as "+ add" near the input item 2 called injection with the pointing device, the cursor keys on the keyboard, etc., and then subcutaneous injection, muscle A module opens that displays dozens of options, such as internal injections. However, in order to reduce the display space, it is desirable that the number of options displayed in the display space is about 10, and all the options are displayed by scrolling.
On the other hand, there are so many choices for disease names, medical practices, tests, and prescriptions, so first enter a keyword by text input, and a module that displays multiple choices related to the keyword opens.
In the present embodiment, the former will be referred to as a minority selection input item, and the latter will be referred to as a majority selection input item.

Next, an example of a specific input method for inputting a large number of selection input items will be described with reference to the image diagrams of the electronic medical record input sheets shown in FIGS. 1 to 4.
First, when inputting to a large number of selection input items called a medical examination act, as shown in FIG. 1, the input start button 4 described as "+ add" immediately below the item is clicked with the mouse. ..

Then, the search word input module 5 opens in the vicinity where the item is displayed (FIG. 2). Then, when a keyword is input to the search word input module 5, a plurality of medical practices related to the keyword are displayed as options (FIG. 3).
More specifically, the keyword which is the character information input to the search word input module 5 and the input item 2 "medical practice" are transmitted to the server via the two-way communication line, and the server sends the character information. Information about a plurality of options to be determined based on the keyword and the "medical practice" which is the input item 2 is transmitted to the browser via the two-way communication line. Then, based on the information regarding the plurality of options, the module 6 for displaying the plurality of options is opened in the vicinity of the display position of the "medical practice" which is the input item 2. When there are many of these options, in order to reduce the display space, it is desirable that the number of options displayed in the display space is about 10, and all the options are displayed by scrolling.

Then, when a doctor or the like selects an option that he / she considers appropriate by clicking or the like, the search word input module 5 and the module 6 that displays a plurality of options are closed and selected near the display position of the input item 2 “medical practice”. Option 7 is displayed (Fig. 4).

When the option 7 is selected and it is necessary to input the attribute related to the option 7, the attribute display 8 is displayed. In the example of FIG. 4, the number of medical treatments of option 7 is an attribute. The attribute display 8 can change the attribute, for example, twice or three times by clicking on it.

In addition, a button 9 for deletion is displayed in order to delete the once entered item.
When the medical practice is a plurality of actions, the medical practice can be added by clicking the input start button 4 described as "+ add".

The size of the search word input module 5 and the module 6 for displaying a plurality of options is preferably the minimum necessary size. The minimum required is that in the case of the search word input module 5, it is sufficient that a space that can be described in the same size as the character size used in the electronic medical record 1 is provided, and a plurality of options are displayed. In the case of the module 6, it is sufficient that a space for displaying about 10 options with characters of the same size is provided. By doing so, each module is easy to see, and the surrounding items are hardly hidden.

<Flow for selecting the option you want to enter>
Next, the flow regarding the above-mentioned input will be described with reference to FIGS. 5 and 6. FIG. 5 is a functional block diagram, and FIG. 6 is a flow diagram. In FIG. 6, the left side is an operation performed by an input person such as a doctor, and the right side is an operation performed by the electronic medical record 1. Further, the black arrow indicates that communication with the server 100 is involved.
First, select the input item 2 you want to input (A1). Specifically, it is selected by clicking the input start button 4 described as "+ add" displayed in the vicinity of the desired input.

As a result, the search means 11 for searching the options is activated, and the search means 11 opens the search word input module 5 in the vicinity of the input item 2 (B1).
Next, a keyword is input to the search word input module 5 (A2).
The search means 11 transmits the input keyword and the input item 2 to the server 100. The server 100 determines information on a plurality of options based on the keyword and the input item 2, and transmits the information. The option display means 12 that receives the information opens the module 6 that displays a plurality of options (B2).

The input person selects an appropriate option from the module 6 that displays a plurality of options (A3).
The selected option is passed to the selection means 13, which closes the search word input module 5 and the module 6 for displaying the plurality of options (B3). Then, the selected option is displayed in the vicinity of the input item 2 (B4).
The above is a series of input operations.

Although the input operation of the majority selection input item has been specifically described, the input operation of the minority selection input item is almost the same except that the search is not performed. That is, in the input operation of the minority selection input item, the option display means 12 for displaying the options and the option display means 12 for displaying the options when the input start button 4 arranged near the display position of the input item 2 is selected. The option display means 12 has a selection means 13 for selecting an option to be input, the option display means 12 opens a module 6 for displaying a plurality of options in the vicinity of the display position of the selection input item 2, and the selection means 13 has a plurality of options. 6 is closed, and the option 7 selected from the plurality of options is displayed in the vicinity of the display position of the selection input item 2.

<Configuration other than the above>
Although the configuration and operation of the electronic medical record according to the embodiment of the present invention have been described, a configuration different from the above is also possible, and an example thereof is shown below.
For the minority selection input items, a search means may be provided so that the options can be narrowed down.
Further, the order of the options displayed in the module 6 for displaying a plurality of options may be arranged in the order of many selections in the past. This makes it possible to streamline the work of selecting options.
Further, it may be necessary to select two or more options from a plurality of options instead of selecting only one option. For example, in the input item "prescription", as shown in FIG. 7, there is an option in which either of the two options may be selected. In such a case, a check box may be provided to the left of the options so that one or both check boxes can be checked.

A confirmation button may be provided in the vicinity of each input item 2. This is to confirm the selected option and send the information to the server 100. Alternatively, a confirmation button may be provided for the entire sheet of the electronic medical record 1 so that the information of the entire electronic medical record 1 can be collectively transmitted to the server.

Further, although the present invention relates to an input method and the like, regarding the display of the completed electronic medical record, the existing medical records of the same patient may be displayed side by side. It is desirable to display the newer chart at the top. One of the features of the browser is that it can scroll up and down at high speed. By arranging the medical records vertically, the medical records of patients from the present to the past can be quickly listed by scrolling up and down.

<Background and Features of the Invention>
The background of the need for the electronic medical record according to the present invention and the features of the electronic medical record according to the present invention are summarized below.
The mainstream of electronic medical records is to input necessary information using a character input device such as a keyboard or a pointing device such as a mouse. This is because, as mentioned above, it is easy to utilize and manage information. However, at present, it is not always easy to use, and there are many problems.

The reason is that the system is configured and the input method is designed without considering the peculiarities of the electronic medical record.
Conventional electronic medical records are being used as a substitute for paper medical records, but they are difficult to operate and require a considerable period of time to get used to. If you use the same electronic medical record every day, it does not matter if it takes some time to get used to it. However, in hospitals and the like, not only full-time doctors but also part-time doctors and doctors who provide temporary medical care may be examined, and it is a big problem that it takes a long time to use the electronic medical record. In order to prevent such problems, some hospitals have assistant staff input electronic medical records instead of doctors, which raises another problem of increased labor costs.

Further, in the case of a medical record that requires a high degree of judgment on the recorded contents, it is desirable to be able to input as flexibly as possible. It is necessary to consider making it easier to input the input items at random rather than in order. In addition, since it is necessary to make advanced judgments while always referring to the entire medical record, it is important that the entire medical record can always be read at the time of input.

In addition, it is necessary to be easy to input so that it can be input while conducting interviews and treatments. The doctor does not just look at the screen of the terminal to input, but listens to the patient and palpates while recording in the medical record. Therefore, it is not preferable to use an electronic medical record in which the position of the electronic medical record being viewed changes while facing the patient. In addition, an electronic medical record in which the response after input is slow or it takes time to rewrite the display is not desirable, and the input cannot be performed at the desired timing, which causes a problem of stressing the doctor during medical treatment.

In addition, various revisions such as examinations, disease names, drug additions and deletions, and remuneration revisions are frequently made, so an electronic medical record that can respond quickly to such revisions is necessary.

In addition, doctors sometimes go to hospital rooms for rounds or visit patients' homes, and do not always use medical records in a good communication environment. Therefore, an electronic medical record that can be used even in an unstable communication environment such as a wireless LAN is desirable.

The present invention has been made in consideration of the peculiarities of such an electronic medical record, and has many excellent features shown below.
First, since it is possible to input with the same feeling as an electronic medical record on paper, it does not require a proficiency period and can be used intuitively. Therefore, it can be easily used not only by doctors who are resident in hospitals, but also by doctors who work once a week.

Secondly, since another sheet does not open, it is easy to input in a random order or rewrite the information once input regardless of the order of the input items.
In addition, since other entered items are not hidden behind another sheet, the general items described in the electronic medical record are always recognizable, and necessary decisions can be made based on the general items described in the electronic medical record. it can.
Furthermore, since input and display are always performed at a nearby position in the sheet, input and confirmation after input can be performed without jumping the line of sight. In particular, since the medical record is usually input while performing medical treatment such as interview and palpation, or treatment, the line of sight goes back and forth between the medical record and the patient. Therefore, if the position of the input or the display is changed while facing the patient, a problem such as visual confusion is likely to occur, but such a problem does not occur in the electronic medical record of the present invention.

Third, because it is a web browser, it can be used immediately without installing an application. In addition, it is possible to immediately respond to various frequently occurring revisions such as examinations, disease names, drug additions and deletions, and reward revisions. That is, it does not require application updates as it does for applications.

Fourth, rewriting the sheet that becomes the medical record is performed at high speed because it is limited to limited modules such as a search word input module and a module that displays multiple options, and limited display data such as selected options. Is possible. In addition, communication with the server is limited to the transmission of search words and the reception of corresponding options, and since both are character information, it is possible to minimize the frequency of transmission and reception and the amount of data to be transmitted and received. .. Therefore, operations such as sheet rewriting can be executed at high speed, and can be used even when the communication environment is unstable.
Since it has such features, the input work can be performed quickly without feeling stress in the input. And since rewriting and the like are performed at high speed, the thinking of doctors and the like is not interrupted, and the judgment is not adversely affected.
It is also possible to input to the medical record by using a mobile device connected by an unstable line such as a wireless LAN at the time of rounds to the hospital room.

1 Electronic medical record 2 Input item 3 Text input field 4 Input start button 5 Search word input module 6 Module to display multiple choices 7 Selected choice 8 Attribute display 9 Button for deletion 11 Search means 12 Choice display means 13 Selection means

100 servers

Claims (2)

A computer, a program for making communication with the server via a bidirectional communication line to perform the process line naive browser,
A plurality of input of the input items that are recorded in the mosquito Rute, which receives boiled single sheet that is displayed by the browser,
The computer
Of the above multiple input items, corresponding to each of the selectable input items that can be selected from the predetermined options,
And choice display means for displaying the choices by Rukoto corresponding input start button arranged near the display position of the selected input item is selected,
A selection means for selecting an option to be input from the options displayed by the option display means,
Among the above selection input items, let it function as a search means for searching for options for selection input items with a wide variety of choices.
By the above-mentioned option display means, a module for displaying a plurality of options is opened near the display position of the above-mentioned selection input item, and the module is opened.
By the selection means, closes the module for displaying the plurality of options, the option selected from the plurality of choices displayed near the display position of the selected input item,
Of the above selection input items, for selection input items with a wide variety of choices,
When the input start button arranged near the display position of the corresponding selection input item is selected by the search means, the search word input module is opened near the display position of the corresponding selection input item.
The character information input to the search word input module and the selection input items are transmitted to the server via the two-way communication line.
Information on a plurality of options determined by the server based on the character information and the selection input items is acquired by the browser via the two-way communication line.
By the option display means, a module for displaying a plurality of options is opened in the vicinity of the display position of the selection input item based on the information regarding the plurality of options.
By the selection means, the search word input module and the module for displaying the plurality of options are closed, and the options selected from the plurality of options are displayed in the vicinity of the display position of the selection input item.
A program to execute processing. The size of the search word input module is configured so that the above character information can be input with the same character size as the character size of the above selection input item displayed on the browser.
The size of the module for displaying the plurality of options is configured so that the plurality of options can be displayed with the same character size as the character size of the selection input item displayed on the browser.
The program according to claim 1 .

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