JPH04195465A - Input backup system for electronic clinical chart system - Google Patents

Input backup system for electronic clinical chart system

Info

Publication number
JPH04195465A
JPH04195465A JP2322961A JP32296190A JPH04195465A JP H04195465 A JPH04195465 A JP H04195465A JP 2322961 A JP2322961 A JP 2322961A JP 32296190 A JP32296190 A JP 32296190A JP H04195465 A JPH04195465 A JP H04195465A
Authority
JP
Japan
Prior art keywords
disease name
menu
main
data
disease
Prior art date
Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
Pending
Application number
JP2322961A
Other languages
Japanese (ja)
Inventor
Yuuichi Tamekuni
為国 雄一
Mihoko Matsuda
松田 美穂子
Kahoru Nakayashiki
中屋敷 かほる
Current Assignee (The listed assignees may be inaccurate. Google has not performed a legal analysis and makes no representation or warranty as to the accuracy of the list.)
Hitachi Ltd
Original Assignee
Hitachi Ltd
Priority date (The priority date is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the date listed.)
Filing date
Publication date
Application filed by Hitachi Ltd filed Critical Hitachi Ltd
Priority to JP2322961A priority Critical patent/JPH04195465A/en
Publication of JPH04195465A publication Critical patent/JPH04195465A/en
Pending legal-status Critical Current

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  • Input From Keyboards Or The Like (AREA)
  • Digital Computer Display Output (AREA)
  • Devices For Executing Special Programs (AREA)
  • Document Processing Apparatus (AREA)
  • Medical Treatment And Welfare Office Work (AREA)

Abstract

PURPOSE:To improve the operability of input operation by searching a diagnostic knowledge menu including main complaints and leading out a matched disease name frame to display disease names, related main complaints, consultation operations, examinations, and prescriptions on a picture and selecting and inputting a required related main complaint. CONSTITUTION:The above system consists of a period menu 20 where main complaints of patients inputted as their views are classified by period, a main complaint menu 21 where they are classified by part, and a diagnostic knowledge menu 22 related to disease names diagnosed in accordance with main complaints and symptoms of patients, consultation operations, examinations, and prescription orders. An inference mechanism collates main complains of a patient with related main complaints in disease name frames of the diagnostic knowledge menu 22 to display information (disease name, related main complaints, medical consultation, examination, and prescription) of the matched disease name. If this inference processing is repeated, the inference mechanism recognizes the frequency in matching to each disease name frame and regards the disease name frame of higher frequency in matching as the disease name frame of higher certainty and displays inference results in the order of frequency in matching, namely, certainty. Thus, the operability is improved.

Description

【発明の詳細な説明】 [産業上の利用分野] 本発明は、電子計算機システムを利用して医療における
カルテに記載する情報を電子化して保持、活用する電子
カルテシステムに係わり、特に所見入力等、カルテ情報
の入力支援方式に関する。
[Detailed Description of the Invention] [Industrial Application Field] The present invention relates to an electronic medical record system that uses an electronic computer system to digitize, maintain, and utilize information to be recorded in a medical record, and particularly relates to an electronic medical record system that uses an electronic computer system to store and utilize information to be recorded in medical records. , relates to a medical record information input support method.

[従来の技術] この種の技術としては、例えば「文章入力方法」(分枝
番号89−3273)に示される技術がある。この技術
は、画像診断レポート作成技術として、文章を単語単位
で入力する情報入力装置において、単語の属するグルー
プの指示を不要にし、入力者に対して次に入力する可能
性の高い単語情報を提示することで文章入力の操作性向
上を図っている。[発明が解決しようとする課題]上記
従来技術では、文章をメニュ一方式で選択入力する際に
、動詞、形容詞の他に、助詞も選択入力をさせているた
め、文章を形成するまでのステップが必然的に多くなり
データ入力の操作性が十分達成されてはいなかった。ま
た、病名や患者の主訴等を推論するという点での配慮が
なかった。
[Prior Art] This type of technology includes, for example, the technology shown in "Sentence Input Method" (branch number 89-3273). This technology is used as an image diagnostic report creation technology for information input devices that input sentences word by word, eliminating the need to indicate the group to which a word belongs, and presenting the inputter with word information that is likely to be input next. By doing this, we aim to improve the operability of text input. [Problems to be Solved by the Invention] In the above-mentioned conventional technology, when selecting and inputting a sentence using a menu method, particles are also selected and input in addition to verbs and adjectives, so there are no steps required to form a sentence. This inevitably resulted in a large number of data entry operations, and the operability of data entry was not sufficiently achieved. Furthermore, no consideration was given to inferring the name of the disease or the patient's chief complaint.

本発明の目的は、上記のステップ数を減らし。The purpose of the invention is to reduce the number of steps mentioned above.

動詞や形容詞等のキーワードが入力された段階で、自動
的に助詞を付加し、正しい日本語を形成する入力支援と
、患者の主訴から考えられる病名のみを診断するのでは
なく、次に考えられる主訴・症状や検査項目までも推論
して、医師に情報を提供し、電子カルテシステムにおけ
る入力操作の操作性向上を図ることにある。
When a keyword such as a verb or adjective is entered, it automatically adds a particle to form the correct Japanese, and the system does not only diagnose the disease name based on the patient's chief complaint, but also the next possible disease name. The purpose is to provide information to doctors by inferring chief complaints, symptoms, and test items, thereby improving the operability of input operations in electronic medical record systems.

[課題を解決するための手段] 上記目的は、患者の主訴・症状をカルテに入力する際、
IIIHEN(イッ)、IIHERE (どこが)、I
IIHAT(どうした)、Hov(どのように)の3す
IH文章構造にしたメニュー選択方式と、部位、箇所、
症状、状態を表す形容詞等を階層的にしたフレーム構造
の知識データを有することと、主訴・症状から推論を行
う際の関連主訴、非関連主訴、病名、検査オーダ、処方
オーダ、診察動作のフレームを有すること。
[Means for solving the problem] The above purpose is to
IIIHEN, IIHERE, I
A menu selection method with a three-step IH sentence structure of IIHAT (what happened) and Hov (how), and parts, places,
Having knowledge data with a hierarchical frame structure of adjectives expressing symptoms and conditions, and a frame of related chief complaints, unrelated chief complaints, disease names, test orders, prescription orders, and examination actions when making inferences from chief complaints and symptoms. to have.

病気の症状や状態を表す各動詞、形容詞のフレーム内に
助詞スロットを有し、入力者に選択された次の階層のデ
ータを順次表示する入力支援方式により達成される。
This is achieved by an input support method that has a particle slot in the frame of each verb or adjective that expresses the symptoms or condition of the disease, and sequentially displays the data of the next hierarchy selected by the inputter.

[作用] 本発明は具体的に、第2図に示すようなフレームベース
の知識構造を持つ。
[Operation] Specifically, the present invention has a frame-based knowledge structure as shown in FIG.

これは、所見入力に関する知識データベースであり、所
見として入力する患者の主訴を時期別に分類した時期メ
ニュー201部位別に分類した主訴メニュー21と患者
の主訴・症状から診断される病名、診察動作、検査、処
方オーダに関する診断知識メニュー22から成る。
This is a knowledge database related to inputting findings, including a time menu 201 in which patients' chief complaints are categorized by period, a chief complaint menu 21 in which they are categorized by body part, disease names diagnosed based on patients' chief complaints and symptoms, examination actions, tests, etc. It consists of a diagnostic knowledge menu 22 regarding prescription orders.

コンピュータの画面には、人間の身体のイラストが第4
図(a)のように表示されているので、人間のイラスト
の中から主訴に関する部位をマウスで選択する。
A fourth illustration of the human body appears on the computer screen.
Since the display is as shown in Figure (a), select the part related to the main complaint from the human illustration with the mouse.

すると、主訴メニュー21より、部位の下位レベルにあ
る”箇所”が表示されるので、この中から更に箇所の選
択を行う。
Then, from the chief complaint menu 21, "locations" at a lower level of body parts are displayed, and the user further selects a location from among these.

同様にして、上位レベルの選択がされると、自動的に下
位レベルの選択肢が表示される、というしくみで入力を
行い、最後に文章の組立てを行う。
Similarly, when a higher-level selection is made, lower-level options are automatically displayed.Input is then performed, and finally the sentence is assembled.

文章の組立てを行う際には、自動的に適当な助詞を付加
する。
When assembling sentences, appropriate particles are automatically added.

そして患者の主訴をカルテに入力した後、推論部は、そ
の主訴が入っている診断知識メニュー22をサーチし、
マツチした病名フレームを導いて病名、関連主訴、診察
動作、検査、処方を画面に表示する。
After inputting the patient's chief complaint into the medical record, the inference section searches the diagnostic knowledge menu 22 containing the chief complaint,
The matched disease name frame is guided and the disease name, related complaint, examination actions, tests, and prescriptions are displayed on the screen.

入力者(医師)は、その中から必要な関連主訴を選択し
て入力を行う。
The inputter (physician) selects and inputs the necessary related chief complaint from among them.

このようにして、入力者は電子カルテシステムに蓄積す
るデータを容易に入力することができる6[実施例] 以下、図面を用いて本発明の一実施例を詳細に説明する
In this way, the inputter can easily input data to be stored in the electronic medical record system.6 [Example] Hereinafter, an example of the present invention will be described in detail with reference to the drawings.

第1図は本実施例の電子カルテシステムを実現するハー
ドウェア構成図である。本システムでは。
FIG. 1 is a hardware configuration diagram for realizing the electronic medical record system of this embodiment. In this system.

入力装置として、キーボード1.マウス2があり、出力
装置としてはCRT3、プリンタ4があり。
As an input device, a keyboard 1. There is a mouse 2, and output devices include a CRT 3 and a printer 4.

これに中央処理装置(CPU)5とデータ格納用のディ
スク装置等の記憶装置6があり、また、外部のコンピュ
ータや各種検査機器と接続し、通信するための通信装置
7より構成される。
This includes a central processing unit (CPU) 5, a storage device 6 such as a disk device for storing data, and a communication device 7 for connecting and communicating with an external computer and various inspection equipment.

第2図は本発明を適用するためのフレームベースの知識
構造図である。フレームベースは記憶装置!!6に格納
され、データ入力時にCPU5が読みだす。
FIG. 2 is a frame-based knowledge structure diagram for applying the present invention. Frame base is a storage device! ! 6, and is read by the CPU 5 when inputting data.

第2図のデータベースはは、所見入力に関する知識デー
タベースであり、所見として入力する患者の主訴を時期
別に分類した時期メニュー2o、部位別に分類した主訴
メニュー21と患者の主訴・症状から診断される病名1
診察動作、検査、処方オーダに関する診断知識メニュー
22から成り、本例は頭部の痛みに関する情報を示して
いる。
The database shown in Figure 2 is a knowledge database related to inputting findings, including a period menu 2o that categorizes patients' chief complaints input as findings by time period, a chief complaint menu 21 that categorizes patients' chief complaints by location, and disease names diagnosed from the patient's chief complaints and symptoms. 1
It consists of a diagnostic knowledge menu 22 regarding examination operations, tests, and prescription orders, and this example shows information regarding head pain.

第3図は本発明全体の処理を示すフローチャートであり
、第4図は本発明を適用するときの表示画面例である。
FIG. 3 is a flowchart showing the overall processing of the present invention, and FIG. 4 is an example of a display screen when the present invention is applied.

ここで、電子カルテシステムに患者の主訴”昨日から、
頭がずきずき痛い”を入力する例を第3図に沿って説明
する。
Here, since yesterday, the electronic medical record system has been displaying the patient's chief complaint.
An example of inputting "My head hurts and throbbing" will be explained with reference to FIG.

まず、第4図(a)に示すような時期メニュー20をC
RT3に表示して(31)、入力者からの「時期」と「
部位」の入力を待つ。入力者(医師)は、表示画面の中
から”昨日から″をマウス2により選択(ピック)する
(31’) (第4図(b))。
First, select the period menu 20 as shown in FIG.
Display it on RT3 (31), and input "time" and "
Wait for input of "part". The inputter (doctor) selects (picks) "From yesterday" from the display screen using the mouse 2 (31') (FIG. 4(b)).

次に、人間のイラストの中から「部位」、今回の場合は
′頭部”を選択する(32)。「部位」の選択情報を受
けると、主訴メニュー21から、頭部に関係のある箇所
1例えば、頭、顔、目、鼻、口などを表示する(33)
(第4図(C))。次に、その中から”頭”が選択され
る(33’)と、頭に関係のある症状、例えば痛い、重
い、ふらふらする、等を表示する(34)(第4図(d
))。
Next, select a “part” from among the human illustrations, in this case “head” (32). When receiving the selection information for “part”, select a part related to the head from the chief complaint menu 21. 1 For example, display the head, face, eyes, nose, mouth, etc. (33)
(Figure 4(C)). Next, when "Head" is selected from among them (33'), symptoms related to the head, such as pain, heaviness, light-headedness, etc., are displayed (34) (Fig. 4(d)
)).

この時点でさらに、′痛い”が選択される(34′)と
、どう痛いのかを表す形容詞が存在するか、どうかを判
断する(35)。今回は第2図に示すように、ずきずき
、ちくちく、刺すように、などの形容詞があらかじめ、
登録されており、形容詞が存在するので、形容詞がある
場合はそれらを表示する(36)(第4図(f))。操
作者は表示された形容詞の中から該当する項目を選択す
る(36’)。
At this point, if 'painful' is selected (34'), it is determined whether there is an adjective that describes how it hurts (35). Adjectives such as , stinging, etc.
Since it is registered and there are adjectives, if there are adjectives, they are displayed (36) (FIG. 4(f)). The operator selects a corresponding item from among the displayed adjectives (36').

もし、形容詞がない場合、例えば、′指に力が入らない
″などは、特に形容詞を必要としないので、その場合は
、形容詞の選択肢を表示せずに、次の処理へ進む。
If there is no adjective, for example, ``I can't put any strength in my fingers'', no adjective is particularly required, so in that case, the process proceeds to the next step without displaying the adjective options.

すべての項目、今回の例では、昨日から、頭、痛い、ず
きずきか入力された時点で、コンピュータは正しい日本
語、′昨日から、頭がずきずき痛い。′に組立てて、カ
ルテに入力できる形にする(37)。その際に必要な助
詞、この場合、′頭部と、′痛い”を結ぶ助詞は、′が
″であるが、′指”と′力が入らない”を結ぶ助詞は ′に”である。このように、助詞は文章によって変化す
るが、′痛い”の前は″が”で、′力が入らない”の前
は′に”になることはある程度明白であるので、第2図
に示すように、主訴メニュー21の症状フレーム中に考
えられる助詞をあらかじめ登録しておく。日本語文章の
組み立て時はそれを参照して日本語を自動的に組立てる
For every item, in this example, when you enter ``Since yesterday, my head hurts,'' the computer responds with the correct Japanese, ``Since yesterday, my head hurts.''' and make it into a form that can be entered into the medical record (37). In this case, the particle that connects ``head'' and ``pain'' is ``ga'', but the particle that connects ``finger'' and ``I can't use my strength'' is ``ni''. In this way, the particles change depending on the sentence, but it is clear to some extent that `` is `` before `` hurt'' and `` ni '' before `` I don't have any strength,'' so they are shown in Figure 2. Possible particles in the symptom frame of the chief complaint menu 21 are registered in advance. When assembling a Japanese sentence, it automatically assembles Japanese by referring to it.

日本語の組立てを終了すると、推論機構は、患者の主訴
′頭が痛い”を診断知識メニュー22の病名フレームに
ある関連主訴とマツチングさせ(38)、マツチする病
名の情報(病名、関連主訴、診察動作、検査、処方)を
表示する(38’)(第4図(g))。
After completing the construction of the Japanese words, the inference mechanism matches the patient's chief complaint, ``My head hurts,'' with the related chief complaint in the disease name frame of the diagnostic knowledge menu 22 (38), and generates information on the matching disease name (disease name, related chief complaint, (38') (Fig. 4 (g)).

推論結果を表示すると、推論を続けるか否かを促すメツ
セージが表示され(39)、Yならば、推論を終了させ
、Nならば始めに戻って、処理を繰り返す、また、これ
らの推論処理を繰り返した場合、推論機構は各病名フレ
ームと何回マツチしたかを把握しており、マツチング数
が多いほど確信度が高いものとみなし、そのマツチング
数の高い順、すなわち、確信度が高い順に推論結果を表
示する。
When the inference results are displayed, a message prompting you to continue inference is displayed (39). When repeated, the inference mechanism knows how many times it matches each disease name frame, and assumes that the higher the number of matches, the higher the confidence, and infers in the order of the number of matches, that is, the order of the confidence. View results.

推論された、病名をカルテに記入する場合も、病名をマ
ウスで選択すると自動的にカルテに記入される。ただし
、病名は患者に知られないように医学専門の略語を使用
する。
When entering the inferred disease name in the medical record, when the disease name is selected with the mouse, it is automatically entered in the medical record. However, medical abbreviations are used to name the disease so that the patient does not know it.

このようにして、患者の主訴を複数回入力して、推論さ
れた結果を医師が参照することにより、診察漏れ、問診
漏れを防ぐことができる。本発明により簡単なキー操作
で入力操作を行うことができる。また、マウスで作業を
行うこともできるので、キーボードに不慣れな医師でも
、カルテへの入力が容易にできる。
In this way, by inputting the patient's chief complaint multiple times and allowing the doctor to refer to the inferred results, it is possible to prevent omissions in examinations and questions. According to the present invention, input operations can be performed with simple key operations. Additionally, since it is possible to work with a mouse, even doctors who are not familiar with keyboards can easily input data into medical records.

[発明の効果] 本発明によれば、キーワードを選択するのみで、自動的
に正しい日本語に組立てることができる。
[Effects of the Invention] According to the present invention, just by selecting a keyword, it is possible to automatically assemble it into correct Japanese.

また、入力選択用の診断知識を、既入力情報と関連のあ
るものに限定して表示を行うので1表示量が少なくてす
み、また、関連した内容に絞りこまれているため、大量
の選択肢の中から必要事項を捜す手間も少なくなり、同
時にこれらの知識は医師が診断する際の手助けとなり、
診断漏れ、問診漏れ、検査漏れを減少する効果がある。
In addition, since the diagnostic knowledge for input selection is limited to those that are related to the information that has already been input, the amount of information displayed per unit is reduced. This reduces the time and effort required to search for the necessary information, and at the same time, this knowledge helps doctors make diagnoses.
It has the effect of reducing missed diagnoses, missed interviews, and missed tests.

【図面の簡単な説明】[Brief explanation of the drawing]

第1図は本発明を適用する処理装置のブロック構成図、
第2図は、本発明を適用するデータベースの知識構造図
、第3図は本発明全体の処理を示すフローチャート、第
4図(a)〜(g)はカルテ入力時の画面の表示例を示
す図、第5図(a)〜(c)は他の画面表示例を示す図
である。 1・・・キーボード、2・・・マウス、3・・・CRT
。 4・・・プリンタ、訃・・中央処理装置(CPU)。 6・・・記憶装置、7・・・通信装置 第1図
FIG. 1 is a block diagram of a processing device to which the present invention is applied;
Fig. 2 is a knowledge structure diagram of a database to which the present invention is applied, Fig. 3 is a flowchart showing the overall processing of the present invention, and Figs. 4 (a) to (g) show examples of screen displays when entering medical records. 5(a) to 5(c) are diagrams showing other screen display examples. 1...Keyboard, 2...Mouse, 3...CRT
. 4...Printer,...Central processing unit (CPU). 6...Storage device, 7...Communication device Fig. 1

Claims (1)

【特許請求の範囲】 1、階層構造の主訴メニューを有し、医療情報を電子デ
ータ化して保持する電子カルテシステムのデータ入力支
援方式であり、上位レベルのデータを表示し、データの
選択がなされたら、下位レベルのデータを次の選択肢と
して順次表示し、全データの選択後主訴メニューに含ま
れる助詞スロットを参照して適当な助詞を付与して文章
の組立を行うことを特徴とする電子カルテシステムの入
力支援方式。 2、病名と、該病名に関する少なくとも関連主訴を含む
関連情報とからなる診断知識を有し、医療情報を電子デ
ータ化して保持する電子カルテシステムのデータ入力支
援方式であり、入力された患者の主訴データを基に診断
知識を用いて病名を推論し、推論結果である病名及び関
連情報を入力用画面に表示することを特徴とする電子カ
ルテシステムの入力支援方式。
[Claims] 1. A data input support method for an electronic medical record system that has a chief complaint menu with a hierarchical structure and stores medical information in the form of electronic data, in which upper-level data is displayed and data selection is made. This electronic medical record is characterized by displaying lower-level data sequentially as the next option, and after selecting all the data, referring to the particle slot included in the main complaint menu and assembling a sentence by adding an appropriate particle. System input support method. 2. This is a data input support method for an electronic medical record system that has diagnostic knowledge consisting of a disease name and related information including at least the related chief complaint regarding the disease name, and stores medical information in electronic form. An input support method for an electronic medical record system characterized by inferring a disease name based on data using diagnostic knowledge and displaying the inference result, the disease name and related information, on an input screen.
JP2322961A 1990-11-28 1990-11-28 Input backup system for electronic clinical chart system Pending JPH04195465A (en)

Priority Applications (1)

Application Number Priority Date Filing Date Title
JP2322961A JPH04195465A (en) 1990-11-28 1990-11-28 Input backup system for electronic clinical chart system

Applications Claiming Priority (1)

Application Number Priority Date Filing Date Title
JP2322961A JPH04195465A (en) 1990-11-28 1990-11-28 Input backup system for electronic clinical chart system

Publications (1)

Publication Number Publication Date
JPH04195465A true JPH04195465A (en) 1992-07-15

Family

ID=18149578

Family Applications (1)

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JP2322961A Pending JPH04195465A (en) 1990-11-28 1990-11-28 Input backup system for electronic clinical chart system

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Cited By (8)

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JP2002163355A (en) * 2000-11-24 2002-06-07 Web Md Kk System and method for managing medical information and recording medium
JP2002236747A (en) * 2001-02-07 2002-08-23 Sanyo Electric Co Ltd Device for inputting diagnosis and treatment data
JP2003038448A (en) * 2001-07-27 2003-02-12 Wako Pure Chem Ind Ltd Item extract system and method therefor, and program for performing processing in system by computer
WO2004046966A1 (en) * 2002-11-20 2004-06-03 Waseda University Icf information processing device and icf information use system using the same
JP2008250543A (en) * 2007-03-29 2008-10-16 Topcon Corp Practice support system and program
JP2010533899A (en) * 2007-04-13 2010-10-28 コーニンクレッカ フィリップス エレクトロニクス エヌ ヴィ Correlating clinical events
JP2010286922A (en) * 2009-06-09 2010-12-24 Fujitsu Ltd Medical examination information entering program, medical examination information entering device and medical examination information entering method
JP2020181342A (en) * 2019-04-24 2020-11-05 キヤノンメディカルシステムズ株式会社 Medical information processing apparatus and medical information processing method

Cited By (8)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
JP2002163355A (en) * 2000-11-24 2002-06-07 Web Md Kk System and method for managing medical information and recording medium
JP2002236747A (en) * 2001-02-07 2002-08-23 Sanyo Electric Co Ltd Device for inputting diagnosis and treatment data
JP2003038448A (en) * 2001-07-27 2003-02-12 Wako Pure Chem Ind Ltd Item extract system and method therefor, and program for performing processing in system by computer
WO2004046966A1 (en) * 2002-11-20 2004-06-03 Waseda University Icf information processing device and icf information use system using the same
JP2008250543A (en) * 2007-03-29 2008-10-16 Topcon Corp Practice support system and program
JP2010533899A (en) * 2007-04-13 2010-10-28 コーニンクレッカ フィリップス エレクトロニクス エヌ ヴィ Correlating clinical events
JP2010286922A (en) * 2009-06-09 2010-12-24 Fujitsu Ltd Medical examination information entering program, medical examination information entering device and medical examination information entering method
JP2020181342A (en) * 2019-04-24 2020-11-05 キヤノンメディカルシステムズ株式会社 Medical information processing apparatus and medical information processing method

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