JPH04333973A - Input/output control method for electronic chart - Google Patents

Abstract

PURPOSE:To obtain the electronic chart system of high reliability and high efficiency by preventing electronic records from being revised, clearly displaying additionally described parts and facilitating the reference of electronic records by permitting only the additional description of diagnostic information inputted last time. CONSTITUTION:When diagnosis is finished and the registering instruction of consultation information is generated (step 18), the storage area of the inputted or additionally described consultation information is designated as an update inhibit area and registered on a storage device (steps 109 and 110). In a step 103, when any irregular identifier is judged, the input error of the identifier is displayed (step 111), a step 109 is started, and the display data of this identifier input error are deisgnated as the update inhibit area and registered on the storage device (step 110) together with the irregular identifier and the date applied in a step 101. Thus, the consultation information inputted to the electronic records can not be updated. On the other hand, the consultation can be additionally described and the additional description can be clearly displayed.

Description

[Detailed description of the invention]

0001

[Industrial Application Field] The present invention relates to an input/output control method for electronic medical records in which medical information handled by doctors is digitized in a medical information system. The present invention relates to an electronic medical record input/output control method suitable for constructing a highly efficient electronic medical record system.

0002

BACKGROUND OF THE INVENTION In recent years, computerization and integration of medical information has been advocated, and in light of the establishment of conventional medical accounting systems, computerization of slip processing is becoming more concrete. The manifestation of this is the electronic input of various orders by doctors, which has already been constructed as a hospital information network,
Examination orders and the like are increasingly being used through physician input. Against this background, we are developing an electronic medical record system that aims to improve the efficiency of operations by digitizing the increasing number of paper medical records to store, store, and operate them, and to improve the efficiency of advanced medical treatment and medical research using computers. Research is underway. However, what is specifically being considered is related to input means for efficiently classifying and managing doctors' medical information on computers, such as expert system construction tools for medical diagnosis. . For example, methods for inputting medical record information, such as those related to inputting findings described in JP-A-1-136277 and those related to inputting diagnostic reports described in JP-A-1-320049, are mainly used to input medical record information. It is not a specific technology for content management or operation. In addition, “Nikkei Computer 1991.3.25 (no. 2)” published by Nikkei BP
49) (1991), page 46, the electronic medical record system stores and manages paper medical records handwritten by doctors as image information in an optical disk device. It is not intended for inputting and managing medical information.

FIG. 7 is an explanatory diagram showing an example of information written in a conventional paper medical chart. The format for filling out paper medical records 55 is currently not standardized, and much of it is left to the discretion of each hospital, department, and doctor. For example, some medical records that are mainly for examinations have examination sheets or sketches printed in advance to make it easier to write in the examination results. However, general medical record entries include the contents shown in FIG. 7. The basic patient information 49 is basic social attributes of the patient and management information within the hospital, which are input at the time of reception of the medical examination. The contents include a patient recognition ID (index), patient name, gender, date of birth, etc. Although not included in the medical record information, information such as the patient's insurance type and contact information is also uniformly managed as basic patient information. The history of present illness/allergies 50 is a description of the medical treatment the patient has received so far and the patient's constitution. The chief complaint 51 mainly includes the content of the interview and the explanation of the patient's medical condition. Regarding the interview,
Some questions may be asked directly by the attending physician, while others may be filled out by the doctor conducting the preliminary examination at the general reception desk, depending on the hospital. Findings 52 describe medical findings. Prescription/
Treatment 53 is a description regarding medication and treatment details. Regarding the prescription/treatment 53, there is an order input system in which a request procedure using a slip, which is performed at the same time as this entry, is performed online electronically via a network. Others 54 is a section for transcribing and pasting test data such as blood pressure, ultrasound photographs, and biochemical tests, and for writing comments on the test results.

0004

[Problems to be Solved by the Invention] In this way, the information written on the paper medical record includes basic patient information such as the patient's name, serial number, gender, and age, the details of orders such as tests and treatments, and , results, current symptoms, findings, and other medical details. Even if these records are replaced with electronic medical records, the content remains the same, although the wording may change. This medical record information is
When it is published on paper, it is characterized by the fact that it can be freely added to and changed so that the progress can be seen, and if someone other than the doctor in charge intentionally falsifies it, it is possible to determine whether or not it was tampered with by looking at the handwriting. . In other words, once entered information cannot be erased (medical record information cannot be erased), and at the same time, the passage of time can be made clear. Another major feature of paper medical records is that the amount of information that can be written on the medical record form can be adjusted to any desired amount by changing the size of the characters or using sketches. Furthermore, in the medical field, the results of various treatments, tests, etc. are delivered to the doctor with a time delay, so medical record information is often not completed all at once but is completed over time. Against this background, when medical record information is digitized and most of the medical information becomes code information, it is necessary to prevent the information from being tampered with and to make it possible to add and change medical information in the same way as in paper medical records. It won't happen.

The problem to be solved is that with the conventional input/output control method for electronic medical records, it is not possible to efficiently perform writing operations and operations corresponding to the current paper medical records using a computer. The purpose of the present invention is to solve these problems of the prior art, to make it possible to input the contents of a medical record such as additional information over time using the same procedure as when handling paper medical records, and to An object of the present invention is to provide an input/output control method for electronic medical records that makes it possible to construct a highly reliable electronic medical record system by preventing falsification of the contents of the electronic medical records.

[0006]

[Means for Solving the Problems] In order to achieve the above object, the electronic medical record input/output control method of the present invention provides: (1) a doctor certified by an input identifier uses a computer to transmit medical information about a patient; This is an input/output control method for electronic medical records that is directly input using a computer.
Based on this detection operation, the storage area for the medical information entered by the doctor in the electronic medical record is designated as an update-prohibited area that prohibits input other than additional input, and is registered in the storage device. It is characterized by displaying the medical information input by the patient as non-rewritable information to prevent falsification of the electronic medical record. (2) In the electronic medical record input/output control method described in (1) above, based on the detection operation of the registration command, the storage area of medical information additionally inputted by the doctor at an arbitrary position in the update prohibited area is updated. The feature is that the area is designated as a prohibited area and registered in the storage device. Also,(
3) In the electronic medical record input/output control method described in (2) above, the additionally inputted medical information is given an attribute that distinguishes it from existing medical information in the update prohibited area, and updated with the additionally inputted medical information. The present invention is characterized in that the existing medical information in the prohibited area is displayed on the screen of the display device with a difference based on the attribute given to the additionally inputted medical information. Also,
(4) In the electronic medical record input/output control method described in (3) above, the display density value is used as the attribute, and the additionally input medical information is displayed on the display device at a density different from the existing medical information in the update prohibited area. It is characterized by being displayed on the screen of (5) In the electronic medical record input/output control method described in (3) above, the display color is used for the attribute, and the additionally input medical information is displayed in a color different from the existing medical information in the update prohibited area.
It is characterized by being displayed on the screen of a display device. Also,(
6) In the electronic medical record input/output control method described in (3) above, display brightness is used as the attribute, and additionally input medical information is displayed at a brightness different from existing medical information in the update prohibited area.
It is characterized by being displayed on the screen of a display device. Also,(
7) In the electronic medical record input/output control method described in any one of (3) to (6) above, the additionally inputted medical information displayed on the screen of the display device and the existing medical information in the update prohibited area, The present invention is characterized in that the additionally inputted medical information is printed out using a printing device with a difference based on the attribute given. (8) In the electronic medical record input/output control method according to any one of (1) to (7) above, the electronic medical record registered in the storage device is controlled by the data processing device used for the input/output of the electronic medical record. It is characterized in that it is output by any data processing device of the connected medical information system. (9) In the electronic medical record input/output control method described in any one of (1) to (8) above, an input operation is performed on the identifier of a doctor who inputs medical information into the electronic medical record. Add the date and time and display it on the screen of the display device,
The present invention is also characterized in that, based on the registration command, the identifier of the doctor to which the date and time have been added is designated as an update-prohibited area and registered in the storage device.

[0007]

[Operation] In the present invention, the doctor in charge inputs the patient's medical information into a predetermined field on the electronic medical record screen displayed on the display device. Here, whether or not the input person is in charge is determined by comparing the identifier such as the name input by the doctor with the identifier previously registered corresponding to the electronic medical record being displayed. After inputting the diagnostic information and registering it in the storage device, save the newly inputted medical information storage area.
Register as an update-prohibited area that prohibits input other than addition by insertion. As a result, the medical information once input cannot be rewritten, thereby preventing falsification of the electronic medical record. In addition, when the doctor in charge makes changes to the diagnostic information in this update-prohibited area, additional input is only possible by insertion, and the additionally input diagnostic information is the same as the previously input medical information. are displayed using different display expressions, for example, different brightness. This makes it easier to see the medical record and allows efficient reference to the medical record during medical treatment. By doing this, even when digitizing diagnostic information that was conventionally recorded on paper medical records and using it in a medical information system, the input of information in the medical records that is performed over time can be done using paper medical records. This can be done using the same procedure as when handling.

[0008]

Embodiments Hereinafter, embodiments of the present invention will be explained in detail with reference to the drawings. FIG. 1 is a flowchart showing one embodiment of processing operations related to the electronic medical record input/output control method of the present invention. The input/output control operation at the doctor's workstation in the medical information system shown in FIG. 2, which will be described later, is shown.
For example, the current date and time are added to the doctor's name and displayed (step 101). Note that this date and time is assigned based on the clock function of the doctor's workstation. Next, it is determined whether this identifier is the attending physician who has authorized the operation of this electronic medical record (step 102). If the identifier is correct (step 103), the doctor uses the keyboard, mouse,
Furthermore, input processing of medical information input via a handwriting tablet or the like (step 104) is performed as follows. If the area to be input is an area in which no medical information has been entered yet (step 105), the input medical information is displayed (step 106), and if the area to be input is the current area Before reading the display, if it is an update-prohibited area where medical information has already been entered, the input medical information can be added (additional input) to create a display state that is different from the already registered medical information, e.g. Color and
Display by brightness, density, etc. (step 107). next,
When the medical treatment is completed and a medical information registration command is issued (step 108), the input or additionally written medical information storage area is designated as an update-prohibited area (step 109), and the information is registered in the storage device (step 110). . Step 103
, an incorrect identifier (e.g., not your doctor)
If it is determined that
11) Proceed to step 109, and designate the display data of this identifier input error, together with the invalid identifier and data such as the date and time assigned in step 101, as an update-prohibited area and register it in the storage device (step 110). In this way, by making it impossible to update the medical information input into the electronic medical record, falsification of the medical information can be prevented. In addition, it is possible to add medical information, and
It is possible to clearly indicate that it is a postscript, and the doctor can
Medical information can be input and output using the same procedures as traditional handwritten medical records. Regarding the method of specifying the update-prohibited area in step 109, that is, the method of protecting computer data, there are various storage protection methods as well-known techniques, and the explanation thereof will be omitted here.

Next, a medical information system in which such an electronic medical record is actually operated will be explained. FIG. 2 is a block diagram showing an embodiment of a medical information system using a doctor's workstation that performs input/output control of the electronic medical record shown in FIG. 1 is an overall configuration diagram of a medical information system that operates an electronic medical record of the present invention, and has the following configuration. The medical information system of this embodiment includes a medical business network 1 for accounting work, etc., which is currently widely used, and files such as the electronic medical record of the present invention, such as medical results input by doctors while meeting patients. A medical department network 2 and B medical department network 3 that perform registration and transfer, an examination department network 4 for examinations specified based on medical results, and a radiology department network 5 that handles high-definition images such as X-ray images. , and a nursing work support network 6 in the ward are connected by a high-speed local area network 7 for large-capacity images such as high-definition images, and a local area network 8 for code information. In this way, a doctor's instructions (orders) from the A clinical department network 2 or the B clinical department network 3 are transmitted via the local area network 8 to the pharmacy department in the medical business network 1 or the laboratory department network 4. A so-called ordering system is established by transmitting information to internal inspection departments, etc., and
A so-called medical image information system is constructed by transmitting medical image information such as X-rays and CT scans that are centrally managed in the radiology network 5 via the high-speed local area network 7. Furthermore, by transmitting the electronic medical record to the nursing work support network 6 in the ward via the local area network 8, for example, the electronic medical record can be referred to on a bedside terminal, resulting in an efficient nursing system. is being built.

[0010] The A clinical department network 2 includes a doctor's workstation 9 (denoted as WS in the figure) which is used by a doctor to input and output the electronic medical record of the present invention when diagnosis is not involved in high-definition images. , a high-definition image doctor's workstation 10 (in the figure, a WS
), and an intra-departmental file device 11 serving as a storage device for registering electronic medical records entered on these physician workstations 9 and high-definition image physician workstations 10.
(denoted as F in the diagram) and a file server 12 (denoted as S in the diagram) that controls the input/output of electronic medical records of the department file device 11 by the doctor workstation 9, high-definition image doctor workstation 10, etc. ), etc. Although not shown, the B medical department network 3 has a similar configuration. With such a configuration, in the medical information system of this embodiment, the doctor's workstation 9 or the high-definition image doctor's workstation 1
The medical information centered on the medical record contents entered in step 0 is sequentially registered and stored in the departmental file device 11, and
Orders for tests, treatments, etc. are transferred to predetermined departments and processed accordingly. The electronic medical record registered in the departmental file device 11 is stored on the doctor's workstation 9 or the high-definition image doctor's workstation 1 when the patient returns or when test data is generated.
It is displayed and output to 0 for reference. Then, when referring to this test data, comments regarding the test results are added to the electronic medical record as needed to complete the electronic medical record. Furthermore, the electronic medical record created in this manner can be output and displayed on a workstation in a nursing work support network for reference via the local area network 8, for example.

The doctor's workstation 9 that performs processing operations according to the present invention will be described in more detail below. FIG. 3 is an actual diagram showing an example of the configuration of a doctor's workstation that performs input/output control operations for the electronic medical record in FIG. 1. In FIG. The doctor's workstation 9 in FIG. 2 and the high-definition image doctor's workstation 10 are shown in external view, and the doctor's workstation 9 in FIG. Workstation body 13 that performs
, a display device 14 for displaying the processing results, a mouse 15 for operating a cursor when inputting coordinates, a handwriting tablet 16 for inputting sketches and handwritten characters, and a keyboard for inputting character codes, etc. The high-definition image doctor's workstation 10 is further equipped with a display device 18 for high-definition image reference. The doctor places these devices on the desk and uses the mouse 15, handwriting tablet 16, and , keyboard 17, etc., the medical information can be directly input.

FIG. 4 is an explanatory diagram showing an example of the process of creating an electronic medical record by the doctor's workstation in FIG. 3. It shows the timing of entries in the electronic medical record 19 by the doctor's workstation during the medical treatment process in the medical information system of FIG. 2, and the timings of entries occur over time, such as month and day. First, at the time of the medical examination 20, an interview is conducted, and basic patient information such as the patient's name, allergies, medical history, gender, date of birth, and the results of the medical examination are entered. And treatment 21
At the time point, treatment orders such as examination orders and radiology orders are entered. Each order entered here is shown in Figure 2.
The information is transmitted to the examination department network 4 and the radiology department network 5 via the local network 8, and the respective examinations (1) 22 to (n) 24 are performed. and,
If the test results can be obtained in a short time, comments such as findings are input at 25:00 of the medical examination, and if the test results require a long time, then comments such as findings are input at 26:00 of the return visit.

FIG. 5 is an explanatory diagram showing an example of the electronic medical record display screen of the doctor's workstation in FIG. 3. The respective entry columns on the screen 27 on the display device 14 of the workstation for digitizing medical record information shown in FIG. By referring to this field, it is determined whether or not the doctor has the authority to input information, and thereafter, only doctors who have permission to treat the patient are allowed to input information. Normally, only the doctor in charge is allowed to enter information, but by going through a predetermined procedure, it is possible to allow doctors in the same department to enter information as well. In the entry column 30, the contents of the interview are entered by a doctor who is permitted to enter the information. The patient's name is entered in the entry field 31, which also serves as the file name of this electronic medical record. In the entry column 32, the history of present illness and
Allergy 50, and in entry field 33, gender,
Some basic patient information such as date of birth is filled in and displayed. The entry field 34 corresponds to the chief complaint 51 and findings 52 of the conventional paper medical record shown in FIG. 7, and the chief complaint and findings are entered therein. The entry field 35 corresponds to the others 54 in FIG. 7, and test data input by the doctor, handwritten information 36, comments 37, and the like are entered. Test result data from automatic testing equipment, etc., can be found in the treatment/problem entry column 38.
are displayed in the respective entry fields 39 to 43. That is, an examination order is entered in the entry field 39, a radiology order is entered in the entry field 40, a prescription order is entered in the entry field 41, a treatment order is entered in the entry field 42, and an admission order is entered in the entry field 43. Ru.

[0014] The allergy information in the entry field 32 is always displayed, and a portion of the medical history is displayed, and furthermore, it can be viewed by scrolling or by clicking to open a new window for displaying the medical history. You can also do it. Similarly, reference to the overall information and actual data entry into each entry field are performed by opening a window for the data entry screen by clicking on each entry field (objective item display area) on the screen 27. Alternatively, for order items that cannot be displayed in the treatment/problem entry field 38, it may be realized by scrolling the area of the treatment/problem entry field 38. Such display control can be performed using so-called multi-window technology, and its explanation will be omitted here. Once the medical information entered in each entry field of the electronic medical record displayed in this manner is registered in a storage device such as the intra-departmental file device 11 in FIG. 2, it becomes an update-prohibited area from then on. From next time onwards, only additional writing by insertion will be permitted in this area. This makes it possible to prevent falsification of medical information.

FIG. 6 is an explanatory diagram showing an example of the electronic medical record display area on the doctor's workstation in FIG. 3. Display device 14 of the workstation in FIG.
2 is a diagram developed in paper format of the electronic medical record file registered in the department file device 11 in FIG. 2, and the workstation display screen 44 is, for example, the screen on the display device 14 of the workstation in FIG. 3, The electronic medical record file 45 is an image of the text portion of the electronic medical record file registered in the intra-departmental filing device 11 of FIG. 2 developed with the same display specifications as paper. In addition, the input prohibited area 46
is the display screen portion of the input portion that has been input up to the time of the current medical examination, and is controlled as an update-prohibited area that cannot be erased or rewritten. The new input area 47 is an area where new input is permitted, and is an area where medical records from the current medical examination are newly input. As shown in FIG. 4, medical records are entered into the electronic medical record at various times depending on the medical treatment content, and the entry position is in the new input area 47.
In addition, there are many cases where it is desired to write in the input prohibited area 46, which is an already input area. For this reason, in this embodiment, an editing function that allows only additional writing is provided to the already inputted area such as the input prohibited area 46, and the density, color, or brightness of the added area 48 is changed. By clarifying information such as this, it is possible not only to ensure falsification prevention, but also to provide a medical record creation environment similar to that used for filling in paper medical records. Further, by scrolling other inputted portions of the electronic medical record file 45, it is possible to move and display them on the screen of the workstation display screen 44,
It is possible to provide an efficient medical record reference operation environment.

As described above with reference to FIGS. 1 to 6, according to this embodiment, the input of medical record contents such as postscript information, which is performed over time, is performed using the same procedure as when handling paper medical records. By preventing falsification of the contents of medical records, it is possible to construct a highly reliable electronic medical record system with good operational efficiency. and,
By digitizing medical records in this way, medical information can be entered sequentially without worrying about the capacity of the medical records, and the medical records can be referenced by a simple scrolling operation, improving operability. Furthermore, since one disease can be added to one file, there is no need to create a new file every time a medical record is entered, and it is possible to prevent file directories from becoming too large. Furthermore, by connecting this electronic medical record system to an existing medical information system, the performance of the medical information system can be improved.

[0017]

[Effects of the Invention] According to the present invention, falsification of the contents of the electronic medical record is prevented by only allowing additions to the medical information input last time, and reference to the electronic medical record is made by clearly displaying the added portion. This makes it possible to construct a highly reliable and highly efficient electronic medical record system.

[0018]

[Brief explanation of drawings]

FIG. 1 is a flowchart showing an embodiment of processing operations related to an electronic medical record input/output control method of the present invention.

FIG. 2 is a block diagram showing an example of a medical information system using a doctor's workstation that performs input/output control of the electronic medical record in FIG. 1;

FIG. 3 is an actual diagram showing an example of the configuration of a doctor's workstation that performs input/output control operations for the electronic medical record in FIG. 1;

FIG. 4 is an explanatory diagram showing an example of the process of creating an electronic medical record by the doctor's workstation in FIG. 3;

FIG. 5 is an explanatory diagram showing an example of the electronic medical record display screen of the doctor's workstation in FIG. 3;

FIG. 6 is an explanatory diagram showing an example of a display area of an electronic medical record screen by the doctor's workstation in FIG. 3;

FIG. 7 is an explanatory diagram showing an example of information written in a conventional paper medical chart.

[Explanation of symbols]

1 Medical work network 2 A clinical department network 3 B medical department network 4 Examination department network 5 Radiology network 6 Nursing work support network 7 High-speed local area network 8 Local area network 9 Doctor's workstation 10 High-definition image doctor's work station 11
Department file device 12 File server 13 Workstation body 14 Display device 15 Mouse 16 Handwriting tablet 17 Keyboard 18 High-definition image reference display device 19 Electronic medical record 20 Examination 21 Treatment 22 Examination (1) 23 Examination (2) 24 Examination ( n) 25 Examination 26 Return examination 27 Screens 28 to 35 Entry fields 36 Test data/handwritten information 37 Comments 38 Treatment/problem entry fields 39 to 43 Entry fields 44 Workstation display screen 45 Electronic medical record file 46 Input prohibited area 47 New input Area 48 Addendum 49 Basic patient information 50 Medical history/allergy 51 Chief complaint 52 Findings 53 Prescription/treatment 54 Others 55 Paper medical record

Claims (9)

[Claims] [Claim 1] A doctor certified with the input identifier,
This is an input/output control method for an electronic medical record in which medical information about a patient is directly input using a computer, and a command to register the electronic medical record displayed on the screen of a display device in the storage medium of the computer is detected, and the detection operation is performed. Based on this, the storage area of the medical information inputted by the doctor into the electronic medical record is designated as an update-prohibited area that prohibits input other than additional input, and is registered in the storage medium, and when the electronic medical record is subsequently referenced, An input/output control method for an electronic medical record, characterized in that the medical information input by the doctor is displayed as non-rewritable information to prevent falsification of the electronic medical record. 2. The electronic medical record input/output control method according to claim 1, based on the detection operation of the registration command,
An input/output control method for an electronic medical record, characterized in that a storage area of medical information additionally inputted by the doctor at an arbitrary position in the update-prohibited area is designated as the update-prohibited area and registered in the storage medium. [Claim 3] In the electronic medical record input/output control method according to claim 2, an attribute is given to the additionally inputted medical information to distinguish it from the existing medical information in the update prohibited area, and the additionally inputted medical information is Electronic medical record input characterized in that the medical information and the existing medical information in the update prohibited area are displayed on the screen of the display device with differences based on attributes given to the additionally inputted medical information. Output control method. 4. The electronic medical record input/output control method according to claim 3, wherein a display density value is used as the attribute, and the additionally inputted medical information is displayed at a density different from the existing medical information in the update prohibited area. An input/output control method for an electronic medical record, characterized by displaying the information on the screen of the display device. 5. In the electronic medical record input/output control method according to claim 3, a display color is used for the attribute, and the additionally input medical information is displayed in a color different from the existing medical information in the update prohibited area. , an electronic medical record input/output control method characterized by displaying the information on the screen of the display device. 6. In the electronic medical record input/output control method according to claim 3, display brightness is used as the attribute, and the additionally input medical information is displayed at a brightness different from that of the existing medical information in the update prohibited area. , an electronic medical record input/output control method characterized by displaying the information on the screen of the display device. 7. In the electronic medical record input/output control method according to any one of claims 3 to 6, the additionally inputted medical information displayed on the screen of the display device and the existing medical information in the update prohibited area. An input/output control method for an electronic medical record, characterized in that the medical information is printed out with a difference based on an attribute given to the additionally input medical information. 8. The electronic medical record input/output control method according to claim 1, wherein the electronic medical record registered in the storage medium is controlled by a data processing device used for inputting/outputting the electronic medical record. An input/output control method for electronic medical records, characterized in that output is performed by any data processing device of a connected medical information system. 9. The electronic medical record input/output control method according to claim 1, wherein the identifier of the doctor who performed the input operation of the medical information into the electronic medical record is associated with the input operation. assigning and displaying the date and time of the procedure on the screen of the display device, and specifying the identifier of the doctor who assigned the date and time in the update-prohibited area and registering it in the storage medium based on the registration command; An electronic medical record input/output control method characterized by: