JP7145366B2 - Document preparation system - Google Patents

Description

The present invention converts vocabularies used in document creation into objects, provides standardized descriptions without fluctuations in expressions, embeds scripts to be executed with respect to the vocabularies, and provides reference links between the lexical objects and the relevant documents/issues. By providing, it relates to a document creation system that automates logical judgment and automatically generates an index.

2. Description of the Related Art In the medical field, etc., it has become common to use a PC for creating medical documents (electronic medical records). Records of doctors and nurses, and instructions (orders) for examinations and treatments are being digitized. There is a movement to analyze medical and nursing care using a large amount of accumulated electronic data (big data) to improve treatment methods.
Prior art documents relevant to this application include: US Pat.

Patent No. 6485164 Patent No. 477994

If the patient's condition is described in a free style, the vocabulary and degree of expression fluctuate, such as fever, high fever, slight fever, or -, +-, ++, or 0 to 5 degrees.
Even if you try to perform statistical processing later, it is difficult to tabulate the same item even though the content is similar.
Also, for example, when a list of cases (medical records) in which symptoms of fever are observed is required, searching the documents of the cases from scratch takes an enormous amount of time and is not practical. Requires construction of a generic index in advance.
There is also a method of restricting the vocabulary used for description with a controlled vocabulary (thesaurus).
However, in the case of drug prescriptions, for example, not only the vocabulary but also the number of tablets per day, the number of doses, the timing of doses, etc. are required to be described in a fixed format.
In addition, it is often necessary to confirm whether the disease name corresponding to the drug has already been registered in the case, or whether the prescription of the drug is contraindicated due to decreased liver or kidney function.
In this way, mere dictionary-like control of vocabulary is not sufficient.

Vocabularies often have common attributes, and recording all attributes repeatedly not only increases the storage capacity but also requires repeated changes in all common attributes when changes are required. , the maintenance work becomes enormous.
Listing only controlled vocabulary makes the document difficult to read.
A form in which controlled vocabulary is embedded in natural sentences is desirable.
Using a vocabulary object that integrates various attributes in a controlled vocabulary risks increasing the storage capacity of the created document.
In the medical field, a clinical path is used in which examinations and treatments to be performed for each disease are developed on a time axis.
Depending on the medical institution, more than 1,000 clinical pathways are used when the specifications of examinations and treatments are changed, and updating the specifications of embedded examinations and treatments is difficult and often causes mistakes. ing.

The present invention has been made to solve such conventional problems, and its object is to object a large number of vocabularies used in a document together with their respective attributes, and create a list that manages the lexical objects. Create a document by arranging vocabulary objects selected from By creating a reference link, the index from the vocabulary object to the document/item is automatically created for later search and retrieval, and semi-automated by embedding the script to be checked at the time of execution in the attribute of the vocabulary object. To provide a lexical object management means with a small storage capacity, good visibility and excellent maintainability by improving security and by factoring common attributes between lexical objects into parent lexical objects to form a parent-child tree structure. , Making it possible to record a large amount of documents with a small recording capacity by providing a means for converting documents containing vocabulary objects that have been edited into plain text, and restoring documents containing vocabulary objects as necessary. To provide a highly functional and maintainable document preparation system by facilitating the update of examinations and treatments embedded in a system.

As means for achieving the object, in the document creation system according to claim 1, there is provided a vocabulary object creating means for creating a vocabulary object integrating a vocabulary and its attributes;
vocabulary object management means for recording and managing created vocabulary objects;
vocabulary object selection means for selecting a necessary vocabulary object from among the vocabulary objects managed by the vocabulary object management means;
a vocabulary object placing means for placing the selected vocabulary object in the document being edited;
It is characterized by comprising reference link means for registering a vocabulary object as a reference link in the vocabulary object management means .

According to claim 2, the document creation system according to claim 1 is characterized in that the document creation system according to claim 1 further comprises script embedding means for recording a script describing an operation to be executed in the vocabulary object.

Claim 3. The document creation system according to any one of Claims 1 and 2 , further comprising comment embedding means for recording a free-form comment to be displayed in the document in the vocabulary object. and

In the document creation system according to claim 4, in the document creation system according to any one of claims 1 to 3, common attributes between vocabulary objects are factored into parent vocabulary objects to organize the group of vocabulary objects into a tree. It is characterized by comprising vocabulary object attribute inheritance means for inheriting an attribute of a vocabulary object to an attribute of a child vocabulary object.

In the document production system according to claim 5, in the document production system according to any one of claims 1 to 4, a vocabulary object/plain text converting means for recording a document containing a vocabulary object as a plain text and lightened document. characterized by comprising

In the document production system according to claim 6, in the document production system according to claim 5, the vocabulary object management means is searched, and based on the mark added to the plain text document, the plain text document is found. and plain text/lexical object conversion means for reviving the vocabulary object .

In the document creation system according to claim 7, in the document creation system according to any one of claims 1 to 6, a plan in which inspections and actions to be performed are developed on a time axis, and inspections and actions to be performed are implemented with vocabulary objects. It is characterized by having a table .

According to claim 8, the document preparation system according to claim 7 is characterized by further comprising specific vocabulary object list display means for displaying a list of locations of specific vocabulary objects.

In the document creation system according to claim 9, in the document creation system according to claim 8 , in the plan table specific vocabulary object list display means, the vocabulary in the plan table specific vocabulary object list is displayed with the changed vocabulary object. It is characterized by comprising plan table specific vocabulary object updating means for updating the object.

Since the document preparation system according to claim 1 comprises the vocabulary object preparation means, the vocabulary object is prepared by integrating the vocabulary and its attributes.
Since the vocabulary object management means is provided, the created vocabulary objects are recorded and managed.
Since the vocabulary object selection means is provided, a necessary vocabulary object is selected from the vocabulary objects managed by the vocabulary object management means.
Since the vocabulary object placement means is provided, the selected vocabulary object is placed in the document being edited.

In the document creation system according to claim 1 , the vocabulary object management means relates to vocabulary objects arranged in a document, and means for reference linking to at least one of (i) the document or (ii) the matter to which the document belongs. have.

Since the document creation system according to claim 2 comprises the script embedding means, the script describing the operation to be executed is recorded in the vocabulary object.

Since the document creation system according to claim 3 is provided with a comment embedding means, the free description comment to be displayed in the document is recorded in the vocabulary object.

In the document creation system according to claim 4 , since the vocabulary object attribute inheritance means is provided, the vocabulary object group is arranged in a tree form by using the parent-child relationship of the content between the vocabulary objects, and the attribute of the parent vocabulary object is transferred to the child vocabulary. Inherited by object attributes.

In the document creation system according to claim 5 , since the vocabulary object/plain text conversion means is provided, it is possible to reduce the recording capacity of the document by converting the document in which the vocabulary object is placed into plain text excluding the object elements. .

Since the document creation system according to claim 6 comprises plain text/vocabulary object conversion means, the plain text document is restored to a document in which vocabulary objects are arranged.

In the document creation system according to claim 7 , since the planning table creation means is provided, the items to be performed are implemented as vocabulary objects in the planning table in which the items to be performed in order to achieve a specific purpose are developed on the time axis. .

In the document creation system according to claim 8 , since the plan table specific vocabulary object list display means is provided, when a specific vocabulary object is changed in the plan table creation means, the list of locations of the vocabulary objects is displayed. indicate.

In the document creation system according to claim 9 , since the planning table specific vocabulary object updating means is provided, the planning table specific vocabulary object list display means displays the changed vocabulary object in the planning table specific vocabulary object list. Update a vocabulary object.

It is an example of a vocabulary object of the present invention. This is an example of the contents of the script attribute item of the vocabulary object of FIG. Fig. 3 is another example of a vocabulary object of the present invention; selecting a necessary vocabulary object from a group of vocabulary objects managed by the vocabulary object management means (lexical object selection means) and placing it in a document (lexical object placement means); FIG. 10 is an explanatory diagram of reference link means for registering at least one of matter IDs as a reference link in the vocabulary object of the vocabulary object management means; 5 is an explanatory diagram of a list of reference links registered in the vocabulary object of the vocabulary object management means shown in FIG. 4; FIG. This is an example of reducing the amount of recording by grouping common parts of attributes of vocabulary objects into the parent vocabulary project. Documents containing vocabulary objects requiring storage capacity are converted to plain text and recorded as lightweight documents, or vice versa, mutual conversion of plain text documents requiring storage capacity to documents containing vocabulary objects requiring storage capacity It is an explanatory diagram for. FIG. 4 is an explanatory diagram for listing vocabulary objects embedded in a clinical path in a vocabulary object management means, and listing updated parts without omission when a vocabulary object is changed.

FIG. 1 is an example of a vocabulary object of the present invention.
As a vocabulary, the drug "Loxonin tablet" is taken up.
Attributes include the number of tablets to be prescribed (1 to 6), the number of divisions of the number of prescribed tablets (1x~), dosage such as dosing time (for example, after breakfast, etc.), number of days to be prescribed, and free input. Attribute items such as comment text and a script recording what should be done when issuing a prescription are illustrated.
The dosage, number of days, etc. are strictly specified in the format for delivery to the software for billing medical fees, so if free description is allowed, delivery becomes difficult.
As shown in FIG. 1, format control to ensure acceptance is essential.
After making a vocabulary object and placing it in a document, strict format control becomes possible by operations such as clicking each attribute item to expand a pull-down menu and selecting it.
It is also important to change the expansion range of the rear attribute (for example, the number of locks is 2 and the number of divisions is 3x or more is impossible) by selecting the front attribute item.
Contents that cannot be expressed in a strict format are grouped into comment attribute items and freely described in text.

FIG. 2 exemplifies the contents of script attribute items in the vocabulary object of FIG.
Various pre-checks on medical safety are required before the drug is actually dispensed based on the prescription document and handed over to the patient.
Search the patient's case document (medical record) in the electronic medical record for the example "Do you have a past history of gastric or duodenal ulcer?" The prescribing physician should be warned on the prescription screen.
Similarly, older people are more prone to side effects, especially those with impaired renal function.
It is necessary to retrieve age and renal function test data from electronic medical records and, if applicable, prompt the prescribing physician to reconsider on the prescription screen.

In addition, it searches whether the applicable disease name of the drug (name of disease for which the drug is allowed to be prescribed) is registered in the electronic medical record, and if it is not registered, displays the list of applicable disease names, Encourage registration.
Warn that prescribing this drug is contraindicated if you have a history of aspirin-induced asthma.
By doing so, the risk of side effects occurring after the patient has taken the drug can be reduced.
In addition, it is possible to prevent an assessment (refusal of payment) after a claim for medical fees is made by preventing omission of registration of disease names.

In FIG. 2, the execution timing of the scripts is either when the prescription document is fixed or when the provisional execution command is given before the prescription document is fixed. Since it may change depending on the situation, such as when the person in charge refers to the document, means for registering the execution timing may be provided.
Regarding the implementation of scripts, any method can be used, such as writing in a scripting language, registering a large number of execution modules written in Javascript, PYTHON, etc., and specifying the necessary execution modules ( scripting means).

FIG. 3 is another example of a vocabulary object of the present invention.
A document in which a doctor or the like describes a patient's symptoms and findings eliminates lexical fluctuations and omissions, and configures a vocabulary object by setting attribute items so that it can withstand later statistical analysis.
With regard to the word body temperature, a numerical value of body temperature (38.2 (° C.) in the example) is freely entered, and the same numerical value is assigned a classification of “3 high fever” based on the classification criteria.
A heat type can be selected from a list, and comment text can be freely entered as necessary.
Since it is difficult to read the medical record document with the list of indications such as "Body temperature 38.2°C high fever remittent fever", we used the free input of comment text to write "Body temperature 38.2°C high fever remittent fever" It is also useful to embed lexical objects in natural sentences such as

FIG. 4 selects a necessary vocabulary object from a group of vocabulary objects managed by the vocabulary object management means (vocabulary object selection means), arranges it in a document (vocabulary object placement means), the document ID of the document, FIG. 10 is an explanatory diagram of reference link means for registering at least one of the matter IDs including the document as a reference link in the vocabulary object of the vocabulary object management means;
The vocabulary object management means manages vocabulary objects in which the vocabulary and its attributes are integrated as a list.
Vocabulary objects include prescription vocabulary objects that require strict format management, such as drug names and blood test names, and description vocabulary objects for describing symptoms and findings. As shown in FIG. 4, lists of prescription vocabulary objects and description vocabulary objects may be managed together or separately.

The vocabulary object selection means and the vocabulary object placement means highlight an appropriate vocabulary object from the vocabulary object list, drag and drop it to the appropriate position in the document being edited, and embed the vocabulary object at the specified position in the document. It is.
The highlighting and drag-and-drop operations may be performed with a mouse or with a fingertip on a touch panel.
Alternatively, a method using arrow buttons or a cursor on the keyboard may be used.
Alternatively, a method of inputting a vocabulary at a specified position of the document with a keyboard or the like, retrieving and selecting the vocabulary from the vocabulary object management means, and embedding it in the document may be used.

A vocabulary object placed in a document also contains at least one of the document ID of the document (such as the record number in the document database that records all documents of all cases) and the ID of the case to which the document belongs (such as the chart number). As reference link means, it is recorded in the vocabulary object in the vocabulary object management means.
As a result, a list of cases and documents in which the object is arranged can be easily obtained. A case ID is sufficient for a case-level search, but a document ID is required for a document-level search.

FIG. 5 is an explanatory diagram of the reference link list of the reference link means registered in the vocabulary object of the vocabulary object management means shown in FIG.
Here, the case ID and document ID of the document in which the object is arranged are recorded for each vocabulary object.

FIG. 6 shows an example in which common parts of attributes of vocabulary objects are grouped into a parent vocabulary project to reduce the amount of recording and improve the visibility of logical relationships between vocabulary objects.
First, as a common script for "non-steroidal analgesics", a script as shown in FIG. 2 is worked out. Regarding "Loxonin tablet", the script of "Non-steroidal pain reliever" is inherited as it is.
"Celecox tablets" partly searches for "whether there is a history of gastric or duodenal ulcers", but it is known to have little adverse effect on ulcers, so only a light warning is given.
In addition, since cardiovascular complications are known, a search is made for "Do you have a history of cardiovascular disease?" and a warning is given if any.

Regarding "Napanol tablets", since it is known that there is no adverse effect on gastric and duodenal ulcers and histamine asthma, this part is deleted from the script inherited from "Non-steroidal analgesics".
By doing so, the storage capacity of the vocabulary objects managed by the vocabulary object management means can be reduced, making it easier to understand the relationships such as mutual differences. It is easy to maintain because changes are inherited by child vocabulary objects.

In FIG. 7, a document containing vocabulary objects requiring a recording capacity is recorded as a plain text document to reduce weight, or conversely, a plain text document containing vocabulary objects requiring a recording capacity is recorded as a lightweight document. FIG. 10 is an explanatory diagram of mutual conversion into a document;
Since the vocabulary object contains a large amount of additional information for editing assistance such as options and scripts, it consumes a large amount of storage capacity of the document as it is.
Therefore, by recording only the edited result as plain text, it is possible to greatly compress the recording capacity.
If the document needs to be re-edited after conversion to plain text, it is necessary to restore the vocabulary object again.
A vocabulary object management means is searched for the vocabulary in the document, and the corresponding vocabulary object is restored. When converting to plain text, it may be useful to mark the vocabulary object part by underlining it or enclosing it in brackets.

FIG. 8 is an explanatory diagram for listing the vocabulary objects embedded in the clinical pathway in the vocabulary object management means by the planning table creation means, and listing the updated parts without omission when the vocabulary objects are changed. is.
Treatment is standardized for each disease, and a process chart (clinical path) for examination and treatment is used, but there are more than 1000 clinical paths in large-scale medical institutions.
When the examination or treatment items in the clinical pathway were updated, it was necessary to visually search for the updated parts and update them one by one. There were many missing updates.
As shown in this figure, for each vocabulary object used in a clinical pathway, clinical pathway IDs and document IDs in which the vocabulary object is used are centrally recorded by means of reference linking, so that leaks can be easily performed. The part to be updated is made clear without any change (specific vocabulary object list display means in plan table).
It would be even more useful if the update was automated (means for updating specific vocabulary objects in plan table).

Although the embodiments have been described above, the specific configuration of the present invention is not limited to the above-described embodiments, and the present invention includes design changes and the like within a range that does not depart from the gist of the invention.
For example, although the electronic medical chart in the medical field has been described as an example, a similar mechanism is effective in areas where document management for each case using controlled vocabulary is suitable, and is included in the present invention. It is also useful to share part or all of the vocabulary object management means with other medical institutions.

Claims (9)

vocabulary object creation means for creating a vocabulary object that integrates the vocabulary and its attributes;
vocabulary object management means for recording and managing created vocabulary objects;
vocabulary object selection means for selecting a necessary vocabulary object from among the vocabulary objects managed by the vocabulary object management means;
a vocabulary object placing means for placing the selected vocabulary object in the document being edited;
A document creation system comprising reference link means for registering a vocabulary object as a reference link in a vocabulary object management means . 2. The document creation system according to claim 1, further comprising script embedding means for recording a script describing actions to be executed in said vocabulary object. 3. The document creation system according to claim 1, further comprising comment embedding means for recording free-form comments to be displayed in said document in said vocabulary object. A vocabulary object attribute inheriting means is provided for factoring common attributes between vocabulary objects into parent vocabulary objects , organizing vocabulary object groups in a tree form, and inheriting attributes of parent vocabulary objects to attributes of child vocabulary objects. The document creation system according to any one of claims 1 to 3. 5. The document creation system according to claim 1, further comprising vocabulary object/plain text conversion means for converting a document containing vocabulary objects into plain text and recording the document as a lightweight document. A plain text/lexical object conversion means is provided for searching the vocabulary object management means and restoring the vocabulary object corresponding to the plain text document based on the mark added to the plain text document. 6. The document creation system according to claim 5. 7. The document creation system according to claim 1, further comprising a planning table in which inspections and procedures to be performed are developed on a time axis and inspections and procedures to be performed are implemented with vocabulary objects. 8. The document preparation system according to claim 7, further comprising a plan table specific vocabulary object list display means for displaying a list of locations of specific vocabulary objects. The plan table specific vocabulary object list display means is characterized by comprising plan table specific vocabulary object update means for updating vocabulary objects in the plan table specific vocabulary object list with the changed vocabulary object. The document creation system according to claim 8.

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