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

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

[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.

[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.

The purpose of the invention is to reduce the number of steps mentioned above.

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.

[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.

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.

[Operation] Specifically, the present invention has a frame-based knowledge structure as shown in FIG.

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.

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.

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.

Similarly, when a higher-level selection is made, lower-level options are automatically displayed.Input is then performed, and finally the sentence is assembled.

When assembling sentences, appropriate particles are automatically added.

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.

The inputter (physician) selects and inputs the necessary related chief complaint from among them.

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.

FIG. 1 is a hardware configuration diagram for realizing the electronic medical record system of this embodiment. In this system.

As an input device, a keyboard 1. There is a mouse 2, and output devices include a CRT 3 and a printer 4.

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.

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.

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.

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.

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.

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)).

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)
)).

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').

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.

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.

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)).

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.

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.

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.

[Effects of the Invention] According to the present invention, just by selecting a keyword, it is possible to automatically assemble it into correct Japanese.

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.

[Brief explanation of the drawing]

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)

[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.