JP7100960B2 - Electronic medical record device and program - Google Patents

Description

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

The electronic medical record device replaces the conventional paper medical record with an electronic system. The electronic medical record device provides a means for inputting a medical record that a doctor or the like has written by hand on a paper medical record into the electronic medical record device (Patent Document 1).

Japanese Unexamined Patent Publication No. 2010-286922

By the way, since doctors and the like enter medical records at the time of medical examination, electronic medical record devices are required to have means for doctors and the like to quickly input medical records. Furthermore, for the purpose of deepening mutual recognition and understanding of medical teams, medical records are being actively utilized.

An object of the present invention is to provide an electronic medical record device and a program that allows a doctor or the like to efficiently input medical records and make extensive use of the input medical records.

The electronic chart device according to the embodiment of the present invention is a meta associated with a description area which is an area where a medical record is input and an area where the input medical record is displayed as a character string or a numerical string. The data contains a SOAP element corresponding to the SOAP for the problem-oriented medical record, the SOAP element is associated with the SOAP sub-region contained in the description area, and the medical record is entered in the SOAP sub-region. If so, the area control unit that reflects the input medical records in the SOAP element associated with the sub-region related to SOAP in the metadata, and the medical records reflected in the SOAP element are stored in a tree structure in the storage unit. The data control unit includes a data control unit that constitutes and stores data in the SOAP information associated with the SOAP element, and the data control unit includes item data obtained by extracting a numerical string from metadata and search data obtained by extracting a character string. , And, display data is generated by extracting information that controls display such as character modification and table included in the medical treatment element, and item data, search data, and display data are stored in the storage unit.

The above embodiment may be a program.

According to the present invention, a doctor or the like can efficiently input a medical record, and the input medical record can be widely utilized.

The block diagram which shows the structure of the electronic medical record apparatus which concerns on this embodiment. The figure which shows the data structure of the medical record information. The figure which shows the structure of the medical record screen. The figure which shows the metadata of the description area. The figure for demonstrating the processing of a data control part. The figure which shows an example of the hardware configuration of a computer.

Hereinafter, embodiments will be described with reference to the drawings.

In the following embodiments, the components (including element steps and the like) are not necessarily essential unless otherwise specified or clearly considered to be essential in principle.

<Device configuration>
FIG. 1 is a block diagram showing a configuration of an electronic medical record device 100 according to the present embodiment. The electronic medical record device 100 includes a storage unit 110, an operation input unit 120, a control unit 130, and a display unit 140.

The storage unit 110 stores the medical record information 500 (see FIG. 2) and various data (image data, character data, etc.) for generating the medical record screen 200 (see FIG. 3).

The display unit 140 displays the chart screen 200. The operation input unit 120 receives an input operation from a doctor or the like for the medical record screen 200.

The control unit 130 generates a medical record screen 200 using the medical record information 500 and various data stored in the storage unit 110, and displays it on the display unit 140. Further, the control unit 130 displays the data input from the operation input unit 120 on the chart screen 200. Further, the control unit 130 reflects the input data in the medical record information 500 stored in the storage unit 110.

Specifically, the control unit 130 includes an area control unit 131, a data control unit 132, and a search unit 133.

The area control unit 131 provides sub-areas of a problem and SOAP according to a problem-oriented medical record (POMR) in a description area which is an area for inputting and displaying medical records. Further, the data control unit 132 stores the medical record input in the sub area of the problem and the medical record input in the sub area of SOAP in a one-to-one relationship in the storage unit 110.

The search unit 133 searches the storage unit 110 for the medical records of each SOAP associated with the problem of the same medical records.

The metadata associated with the description area includes a problem element corresponding to the problem and a SOAP element corresponding to SOAP. Problem elements and problem sub-regions are associated. The SOAP element and the SOAP subregion are associated. The area control unit 131 reflects the medical care record input to the sub-region of the problem in the problem element in the metadata, and reflects the medical care record input to the sub-region of SOAP in the SOAP element in the metadata. The data control unit 132 stores the medical record in the problem element and the medical record in the SOAP element reflected in the metadata in a one-to-one relationship in the storage unit.

The metadata associated with the description area, which is the area for inputting and displaying medical records, includes SOAP elements corresponding to SOAP for problem-oriented medical records. The SOAP element and the sub-region contained in the description area are associated with each other. The area control unit 131 reflects the medical record input in the sub area in the metadata. The data control unit 132 stores the medical record reflected in the metadata in the storage unit 110.

When the medical care record is input to the sub-region, the area control unit 131 adds the medical care element corresponding to the input medical care record in the SOAP element associated with the sub-region in the metadata.

The data control unit 132 stores the medical care record in the medical care element included in the metadata in the storage unit 110 in association with the attribute information of the medical care element.

The area control unit 131 displays the order cost area, which is an area for inputting and displaying the order cost, and the description area side by side.

When the copy was executed for the medical record in the description area, the area control unit 131 copied the medical element containing the medical record in the metadata and pasted the copied medical record. If so, add the medical care element containing the copied medical care record to the metadata.

These operations will be described in detail below.

<Medical record information>
FIG. 2 is a diagram showing a data structure of the medical record information 500.

Doctors and the like input medical records according to POMR. Therefore, the medical record information 500 has a data structure suitable for POMR.

The medical record information 500 includes the examinee information 502, the examination history information 504, the examiner information 506, the problem information 508, and the SOAP information. The medical record information 500 is created for each examinee information 502.

The examinee information 502 includes information about the examinee (patient). The information about the examinee is, for example, the examinee's ID, name, age, gender, address, telephone number, and the like. The examinee information 502 has at least one examination history information 504 as a child node.

The consultation history information 504 includes information on the date when the examinee of the examinee information 502 received a consultation. The consultation history information 504 has at least one examiner information 506 as a child node.

The examiner information 506 includes information about the examiner who examined the examinee of the examinee information 502 on the date of the examination history information 504, and the time when the examiner examined. The information about the examiner is, for example, the examiner's ID, name, affiliation, and the like. The examiner is not limited to doctors and nurses, but includes a wide range of medical professionals such as medical office workers. The examiner information 506 has at least one problem information 508 as a child node.

The problem information 508 includes information for identifying the "problem" identified by the examiner in the examiner information 506. The information for identifying the "problem" is, for example, the ID of the "problem", the name of the "problem", or the like. The "problem" in POMR is not limited to a mere disease name, but may be, for example, a symptom, a surgical content, or the like, or may be the name of a clinical department or a doctor. That is, a medical institution that uses an electronic medical record device can freely use the "problem".

The problem information 508 has one SOAP information (S information 510, O information 512, A information 514, P information 516) as a child node. The reason why one problem information 508 has one SOAP information 516 as a child node is that POMR recommends to describe "SOAP" for each "problem".

The S information 510 is the information of Subjective Data in POMR. O information 512 is information of Objective Data in POMR. The A information 514 is the information of the Assessment in POMR. P information 516 is information of Plan in POMR.

By associating one SOAP information with one problem information 508 in this way, it becomes easy for the search unit 133 to search the SOAP information using the problem information 508 as a search key. As a result, the examiner can refer to the SOAP information input by another examiner for the same "problem" and reuse the SOAP information. That is, the electronic medical record system can promote the utilization of the medical record information 500.

FIG. 3 is a diagram showing a medical record screen 200.

The medical record screen 200 has a medical record item list 202, an order item list 204, a examinee header 205, a medical record article description area 206, and an order cost area 208.

The content of the examinee information 502 is displayed in the examinee header 205.

In the medical record article description area 206, a list of medical records of the examinee displayed in the examinee header 205 is displayed.

The order cost area 208 is an area for inputting the order cost for the examinee displayed in the examinee header 205. In the order cost area 208, the medical staff can input the medicine to be ordered from the pharmacy or input the test content to be ordered from the laboratory.

The medical record article description area 206 has a consultation history header 217, a consultation header 218, and a description area 219.

In the consultation history header 217, the contents of the consultation history information 504 of the examinee are displayed. The content of the examiner's examiner information 506 is displayed in the examination header 218.

The description area 219 is an area in which the medical examination record of the examinee can be displayed and the medical examination person can input and edit the medical examination record of the examinee. The description area 219 can switch between an input mode and a display mode. In the display mode, the area control unit 131 analyzes the contents of the metadata written in the markup language such as XML, XHTML, and HTML, and displays the contents in the description area 219. The area control unit 131 controls the description area 219 as an editor (for example, HTML editor) whose metadata can be edited by WYSIWYG (What You See Is What You Get) in the input mode.

Thereby, the character string and the numerical string arbitrarily input to the description area 219 by the doctor or the like in WYSIWIG can be handled as text data and numerical data, respectively, on the computer. In addition, the data type of numerical data can also be handled.

FIG. 4 is a diagram showing metadata 300 related to the description area 219. Hereinafter, the processing of the area control unit 131 and the data control unit 132 when the examiner inputs the medical care record to the description area 219 will be described with reference to FIGS. 2 to 5.

<Initialization>
The area control unit 131 first generates metadata 300 including a "problem" element 302, an "S" element 304, an "O" element 306, an "A" element 308, and a "P" element 310. , The content is displayed in the description area 219.

As a result, the description area 219 includes a problem area 220 corresponding to the "problem" element 302, an S area 221 corresponding to the "S" element 304, an O area 222 corresponding to the "O" element 306, and "A". The A region 224 corresponding to the element 308 and the P region 226 corresponding to the "P" element 310 are displayed. The regions 220, 221 and 224, 226 included in these description regions 219 are examples of sub-regions.

<Input of medical records>
The examiner can input medical records in each area via the operation input unit 120. If the "problem" has not yet been determined, the examiner inputs (or selects) data indicating that fact (for example, "common" or "indefinite") in the problem area 220.

In POMR, it is recommended to describe SOAP for each problem. Therefore, when the area control unit 131 receives an instruction to create a new description area 219 from the examiner, the area control unit 131 executes the above initialization process and separately creates a description area 219 including the problem area and the SOAP area associated with the problem area. do.

<BMI input>
Hereinafter, an example in which the examiner inputs a numerical string relating to the examinee's BMI in the description area 219 will be described. However, this is just an example, and various character strings and number strings can be input in the description area 219.

(ST10) When the examiner selects the folder O210 from the left column of the medical item list 202, the area control unit 131 displays the medical item belonging to the folder O210 in the right column of the medical item list 202.

(ST12) Next, when the examiner selects the medical treatment item "BMI" 212 from the medical treatment items displayed in the right column of the medical treatment item list 202, the area control unit 131 "O" of the metadata 300. The "BMI" element 404 is added to the contents of the element 306. This "BMI" element 404 has a "height" element 450, a "weight" element 451 and a "BMI value" element 452 as element contents. The elements related to the metadata corresponding to these medical care items are examples of medical care elements.

As a result, in the O region 232 of the description region 219, the height region 240 corresponding to the "height" element 450, the weight region 242 corresponding to the "weight" element 451 and the BMI value corresponding to the "BMI value" element 452. Area 244 and is displayed.

(ST14) Next, when the examiner inputs the examinee's height "160" in the height area 240, the area control unit 131 changes the content 420 of the "height" element 450 of the metadata 300 to "160". do. As a result, "160" is displayed in the height area 240 of the description area 210. The same applies to "weight".

The "BMI value" element 452 is associated with a calculation formula using the latest "height" element and "weight" element in advance. Therefore, the area control unit 131 calculates the "BMI value" from the input "height" and "weight" using this calculation formula, and changes the content 424 of the "BMI value" element 452 to the calculation result. do. As a result, the "BMI value" is automatically displayed when the examiner inputs the "height" and the "weight".

<Shamer input>
(ST30) When the examiner selects the folder O210 in the medical examination item list 202 and selects the medical examination item “schema” 211 from the left column, the area control unit 131 displays various schema images (not shown).

(ST32) Next, when the examiner selects a schema image of the oral cavity from the various schema images, the region control unit 131 adds the content of the “O” element 306 of the metadata 300 to the schema element 403 of the oral cavity. And change the content of the oral schema element 403 to the file name 425 of the oral schema image. As a result, the schema image 230 of the oral cavity is displayed in the O region 222 of the description region 219.

<Character modification>
When the examiner selects the character string "anti-inflammatory analgesic" 254 in the P area 226 and presses the underlined shortcut key, the area control unit 131 and the area control unit 131 are meta so that the character modification can be understood. The character string "anti-inflammatory analgesic" 426 of the content of the "P" element 310 of the data 300 is changed to be surrounded by, for example, a "u" tag. As a result, an underline is displayed in the character string "anti-inflammatory analgesic" 254 in the P region 226. The "u" tag is an example of character modification information, and the character modification information may be held in a format other than the tag.

<Copy and paste>
The examiner selects "160" entered in the height area 240 and presses the copy shortcut key, moves the cursor to the paste destination, and presses the paste shortcut key. Then, the area control unit 131 copies to the position corresponding to the paste destination in the unit of the "height" element 450 of the metadata 300. This makes it possible to copy the meaning of the data "160" (in this case, the meaning of "height") and the character modification information. The same applies to cut and paste.

In addition to the above-mentioned copy function, the area control unit 131 also has a function of copying only a character string (number string). The examiner can select and utilize these different copy functions.

By using the data format of a predetermined markup language (for example, HTML) as shown in FIG. 4, the description is made not only in the application peculiar to the electronic medical record device 100 (so-called native application) but also in the so-called general-purpose Web browser. The contents input to the area 219 can be displayed in the same manner without breaking the structured state.

The electronic medical record device 100 internally manages information including the above character modification and the like in a predetermined data structure, and converts the internal data into HTML data as shown in FIG. 4 at the output stage to the screen. And output.

<Reflecting the entered medical record in the medical record information>
The data control unit 132 reflects the data input to the description area 219 by the examiner, that is, the content of the metadata 300 shown in FIG. 4 in the medical record information 500 shown in FIG. 2, as described below.

The data control unit 132 reflects the "problem" element 302 in the problem information 508. The data control unit 132 reflects the "S" element 304 in the S information 510. The data control unit 132 reflects the “O” element 306 in the O information 512. The data control unit 132 reflects the “A” element 308 in the A information 514. The data control unit 132 reflects the "P" element 310 in the P information 516.

Hereinafter, a specific example of reflecting the “O” element 306 in the O information 512 will be described.

When the data control unit 132 reflects the "height" element 450 included in the content of the "O" element 306 in the O information 512, the data control unit 132 not only reflects the content "160" of the "height" element 450 but also the "height" element. The 450 attribute information "height_value" and "cm" are also reflected.

In this way, by also reflecting the attribute information of the element, the numerical value and the character string included in the medical record information 500 can have a meaning (meta information). As a result, the search unit 133 can search the medical record information 500 by the attribute information, and the medical record information 500 can be easily utilized.

<Order cost area>
Hereinafter, the processing of the area control unit 131 when the medical worker inputs the order cost to the order cost area 208 will be described with reference to FIG.

(ST60) When the healthcare professional selects the medication 214 from the order item list 204, the region control unit 131 displays a list of agents belonging to the medication 214 (not shown).

(ST62) Next, when the medical staff selects the drug "Flomox Tablets 75 mg" from the list of the displayed drugs, the region control unit 131 sets the selected drug "" in the order cost region 208. Flomox Tablets 75 mg "260 and the dose input area 264 for the drug 260 are displayed.

(ST64) Next, when the healthcare professional selects the dose input area 264, the control unit makes the dose input area 264 editable.

(ST66) The healthcare professional then inputs, for example, a "3" tablet into the editable dose input area 264.

In this way, the healthcare professional can enter the order cost in the order cost area 208.

The area control unit 131 may form another order area for each order destination in the order cost area 208. In this case, the area control unit 131 controls to copy and paste the order cost input to one order section to another order section according to the operation of the medical staff.

When the medical record article description area 206 and the order cost area 208 are separate screens, the medical staff needs to select the screen to be input. This is a cumbersome operation for healthcare professionals.

Therefore, as shown in FIG. 3, the area control unit 131 displays the medical record article description area 206 and the order cost area 208 side by side on the medical record screen 200. This eliminates the need for the medical staff to perform screen selection operations.

Further, the medical staff can easily copy and paste the data of the description area 219 into the order cost area 208, and conversely, copy and paste the data of the order cost area 208 into the description area 219. become.

As a result, medical professionals can efficiently input medical records and the like.

FIG. 5 is a diagram for explaining the processing of the data control unit 132.

The data control unit 132 processes the metadata 300 corresponding to the description area 219 so as to be easy to utilize, and stores it in the storage unit 110 (or reflects it in the medical record information 500).

The data control unit 132 extracts objective numerical values such as height, weight, and body temperature from the metadata 300, and creates data (referred to as “item data”) 506 for handling each item such as numerical values independently. , Stored in the storage unit 110 (or reflected in the chart information 500). As a result, statistics, graphs, and the like using objective numerical values and the like can be easily created from the medical record information 500 stored in a large amount in the storage unit 110.

Further, the data control unit 132 extracts and processes a character string and the like descriptively input by a doctor or the like from the metadata 300 to generate search data 504, and stores it in the storage unit 110 (or in the chart information 500). reflect. As a result, desired information can be searched at high speed from the medical record information 500 stored in a large amount in the storage unit 110.

Further, the data control unit 132 extracts from the metadata 300 including information for controlling character modification and display such as a table, generates display data 502, and stores it in the storage unit 110 (or reflects it in the chart information). do. As a result, the medical record information 500 is held in the storage unit 110 without losing the additional information such as the character modification input by the doctor or the like.

In this way, by generating the display data 502, the search data 504, and the item data 506 from the metadata 300 and storing them in the storage unit 110, the range of utilization of the medical record information 500 is expanded.

<Additional Notes>
FIG. 6 is a diagram showing a hardware configuration of a computer that programmatically realizes the functions of each part in the above-described embodiments and modifications.

As shown in FIG. 6, the computer 2100 includes an input device 2101 such as an input button and a touch pad, an output device 2102 such as a display and a speaker, a CPU (Central Processing Unit) 2103, a ROM (Read Only Memory) 2104, and a RAM (Random). Access Memory) 2105 is provided. Further, the computer 2100 reads information from a hard disk device, a storage device 2106 such as an SSD (Solid State Drive), a recording medium such as a DVD-ROM (Digital Versaille Disk Read Only Memory), and a USB (Universal Serial Bus) memory. 2107, a transmission / reception device 2108 that communicates via a network is provided. The above-mentioned parts are connected by the bus 2109.

Then, the reading device 2107 reads the program from the recording medium on which the program for realizing the functions of the above parts is recorded, and stores the program in the storage device 2106. Alternatively, the transmission / reception device 2108 communicates with the server device connected to the network, and stores the program for realizing the functions of the above-mentioned parts downloaded from the server device in the storage device 2106.

Then, the CPU 2103 copies the program stored in the storage device 2106 to the RAM 2105, sequentially reads the instructions included in the program from the RAM 2105, and executes the program, whereby the functions of the above parts are realized. Further, when the program is executed, the information obtained by the various processes described in each embodiment is stored in the RAM 2105 or the storage device 2106, and is appropriately used.

For example, in the electronic medical record device 100 shown in FIG. 1, the operation input unit 120 corresponds to the input device 2101, the display unit 140 corresponds to the output device 2102, the storage unit 110 corresponds to the storage device 2106, and the control unit 130 corresponds to the storage device 2106. Corresponds to CPU2103.

The embodiments described above are examples for the purpose of explaining the present invention, and the scope of the present invention is not limited to the embodiments. Those skilled in the art can practice the invention in various other embodiments without departing from the gist of the invention.

The electronic medical record device and program according to the present invention are suitable for use in a system or computer that handles electronic medical records.

100 Electronic medical record device 110 Storage unit 120 Operation input unit 130 Control unit 131 Area control unit 132 Data control unit 133 Search unit 140 Display unit 200 Medical record screen 206 Medical record article description area 208 Order cost area 219 Description area 300 Metadata 500 Chart information

Claims (7)

The metadata associated with the description area, which is the area where the medical record is input and the area where the input medical record is displayed, corresponds to the SOAP related to the problem-oriented medical record. Contains SOAP elements and
The SOAP element is associated with a sub-region relating to the SOAP contained in the description region.
When a medical record is input to the sub-region related to SOAP, a region control unit that reflects the input medical record in the SOAP element associated with the sub-region related to SOAP in the metadata.
The medical record reflected in the SOAP element is provided with a data control unit that constitutes a tree structure in the storage unit and stores it in the SOAP information associated with the SOAP element.
The data control unit
From the metadata, the item data obtained by extracting the numerical string, the search data obtained by extracting the character string, and the display data obtained by extracting the information controlling the display of the character modification and the table included in the medical treatment element are generated. Then, the item data, the search data, and the display data are stored in the storage unit.
Electronic medical record device. The metadata corresponds to the problem related to the problem-oriented medical record, is associated with the SOAP element, and reflects the medical record input to the sub-region related to the problem included in the description area. Including additional problem elements to be
The data control unit constitutes a parent node of the SOAP information in the tree structure and stores the medical record reflected in the problem element in the problem information associated with the problem element.
The electronic medical record device according to claim 1. When a medical record is input to the sub-region, the area control unit adds a medical element corresponding to the input medical record to the SOAP element associated with the sub-region in the metadata. ,
The electronic medical record device according to claim 1. The data control unit stores the medical care record in the medical care element included in the metadata in the storage unit in association with the attribute information of the medical care element.
The electronic medical record device according to claim 3. The area control unit displays the order cost area, which is an area for inputting and displaying the order cost, and the description area side by side.
The electronic medical record device according to claim 1. The area control unit
When the copy is executed for the medical record in the description area, the medical element containing the medical record in the metadata is copied.
When the past of the copied medical record is executed, the medical element containing the copied medical record is added to the metadata.
The electronic medical record device according to claim 1. A program for making a computer function as an electronic medical record device.
On the computer
The metadata associated with the description area, which is the area where the medical record is input and the area where the input medical record is displayed, corresponds to the SOAP related to the problem-oriented medical record. It contains a SOAP element, and the SOAP element is associated with a subregion relating to the SOAP contained in the description area.
On the computer
When a medical record is entered in the SOAP sub-region, the step of reflecting the entered medical record in the SOAP element associated with the SOAP sub-region in the metadata.
A step of forming a tree structure in the storage unit and storing the medical records reflected in the SOAP element in the SOAP information associated with the SOAP element, and
From the metadata, the item data obtained by extracting the numerical string, the search data obtained by extracting the character string, and the display data obtained by extracting the information controlling the display of the character modification and the table included in the medical treatment element are generated. Steps to do and
A step of storing each of the item data, the search data, and the display data in the storage unit, and
A program to execute.

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