JPH08335239A - Medical chart generation support device - Google Patents

Abstract

PURPOSE: To reduce the trouble required for the generation, management, etc., of medical charts by holding a read partial picture in relation with given medical treatment data and recording those medical treatment data and partial picture as specific positions on a specific form. CONSTITUTION: For, for example, an oral surgical treatment, position registration data which are registered as medical chart data are read out and a position is specified with the read position registration data. Consequently, corresponding partial pictures are read out of a vertical teeth expansion picture file and a horizontal teeth expansion picture file recorded on a hard disk 13. The read partial pictures are displayed together with the registered medical chart data. A dentist deletes unnecessary pictures or writes additional contents of patient's conditions or a treatment. When the contents of the oral surgical treatment are confirmed, the contents of medication are recorded on the medical chart 14. Namely, a medication screen file is read out, its screen is displayed on a display 9, and the medical chart data are stored on a floppy disk 14.

Description

Detailed Description of the Invention

[0001]

BACKGROUND OF THE INVENTION 1. Field of the Invention The present invention relates to an apparatus for supporting the preparation of medical records recorded by doctors, so-called medical charts. In particular, the present invention relates to a device suitable for supporting the creation of a dental chart.

[0002]

2. Description of the Related Art Taking dental treatment as an example, when a dentist treats a patient, the content of the treatment is recorded in a dental chart for each patient. One of the characteristics of the record of the dental chart is that the tooth to be treated and its periphery are shown. In addition, when medical treatment is provided by insurance, a prescribed portion of the medical treatment cost must be billed to the insurance organization (so-called insurance claim). In order to make an insurance claim, it is required that a picture showing the treatment content is recorded in the dental chart together with the medical treatment content. Furthermore, it is necessary to fill in a score according to the content of medical treatment defined by the insurance organization in the insurance claim.

By the way, in dental treatment, examination and treatment are performed almost at the same time, and necessary treatment is performed while looking into the oral cavity of the patient lying on his or her back on the examination table.
The patient must have a large open mouth during the medical treatment, and long-term medical treatment is a pain for the patient. Therefore, medical treatment can be carried out quickly and quickly, and one medical treatment time for one patient is usually about 30 minutes to 1 hour.

Further, in order to reduce the waiting time of patients who come to the medical examination, generally, the medical examination time is reserved. Reservation takes into account the medical treatment time for each patient, for example, 1
Accepted in 5 to 20 minute units. Therefore, the dentist during the medical treatment time has to treat the patient one after another, which is very busy.

[0005]

In the present situation of such dental treatment, the dentist is required to treat each patient after each treatment.
There is no time to slowly record the details of medical treatment in the dental chart. In particular, when a patient has undergone treatment such as incision, tooth extraction, and suturing, the treatment location and treatment content must be shown in the picture, but there is currently no time to write such a picture in the dental chart. is there.

In other words, the dentist must record the medical treatment contents in the dental chart in the meantime while treating many patients one after another. Therefore, the advent of a mechanical system that supports the creation of records for dental charts has been desired. The annoyance of creating a medical record is not limited to dentistry, and is the same in other medical fields such as surgery, internal medicine, and otolaryngology. Further, in any medical field, as the number of patients increases, the number of medical records also increases. Therefore, there is a demand for not only the medical record preparation work but also the efficient storage and management of medical records.

The present invention has been made under such a background, and its main purpose is to utilize a computer system to reduce the time and effort required for creating and managing a medical record. It is to provide a support system. Another object of the present invention is to provide a medical record creation support device that assists in recording a picture of a treatment site and treatment contents when creating a medical record.

Still another object of the present invention is to provide a medical record preparation assisting apparatus capable of automatically recording a score defined by insurance medical care regulations in a medical record in association with medical treatment when performing medical treatment for insurance. That is. Still another object of the present invention is to provide a medical record making support device in which, when a specific medical treatment is recorded in a medical record, a disease name corresponding to the medical treatment is automatically recorded.

[0009]

According to one aspect of the present invention, when viewed from a certain aspect, a storage means in which a picture representing the arrangement of teeth including a predetermined number of teeth is stored, and the storage means is stored in the storage means in accordance with given treatment data. Readout means for reading out a partial picture including teeth of a portion corresponding to treatment data from a stored picture, holding means for holding the read partial picture in association with given treatment data, and the holding means. It is a dental chart preparation support device characterized by including recording means for recording the held treatment data and partial pictures at a predetermined position on a chart sheet.

According to another aspect of the present invention, a storage means storing a plurality of pictures of dentures, and a treatment among the pictures of dentures stored in the storage means according to given treatment data. The reading means for reading the picture corresponding to the data, the holding means for holding the read picture in association with the given treatment data, and the treatment data and the denture picture held in the holding means are stored on a medical chart sheet. It is a dental chart preparation support device including a recording means for recording at a predetermined position.

Viewed from still another aspect, the present invention is
Storage means for storing a plurality of types of pictures of a part of a human body to be treated, and reading means for reading out a picture corresponding to the treatment data among the pictures stored in the storage means according to the given treatment data Holding means for holding the read picture in association with the given treatment data, and recording means for recording the treatment data and the picture held in the holding means at a predetermined position on the medical chart sheet. Is a medical record creation support device.

From a further aspect, the present invention provides medical content log point storage means in which a relationship between medical content and points defined by insurance medical regulations is recorded, and medical content to be recorded in a medical record. Then, when a score is set for the given medical care content by searching the storage means, a reading means for reading the score and a score read by the reading means for the given medical care content. And a recording means for recording in a medical record in association with the medical record creation support device.

Further, according to another aspect of the present invention, when a plurality of treatments and a treatment name storage means in which a plurality of treatment candidates predicted from each treatment are stored, and a treatment to be recorded in a medical record are given. A treatment storing means for storing a given treatment, a reading means for searching the treatment vs. disease name storing means on the basis of the treatment stored in the treatment storing means, and reading out a disease name candidate predicted from the treatment, And a holding unit that holds the disease name candidate read by the reading unit as a disease name to be recorded in a medical record, and the reading unit, when a new treatment is additionally stored in the treatment storage unit,
Based on a plurality of treatments including the additionally stored treatments, it is a reading means for searching the treatment vs. disease name storage means and reading out a disease name candidate satisfying all the treatments, wherein the holding means is the reading means. The stored disease name is updated by the read disease name candidate,
It is a chart creation support device.

[0014]

According to the first to third aspects of the present invention, when a picture of a medical examination site or medical examination contents is recorded in the medical chart, the picture of the medical examination site is read from the storage means and automatically recorded. Therefore, it is not necessary to manually write a picture of the medical examination site on the medical record. According to the invention of claim 4, the points determined by the insurance medical care regulations are automatically recorded in association with the medical care contents recorded in the medical record.

According to the fifth aspect of the present invention, by recording the treatment content in the medical record, the disease name candidate is automatically recorded.
Therefore, it is only necessary to delete inappropriate disease names from the recorded disease name candidates, which makes it convenient to create a medical chart. In particular, in dentistry, the treatment content usually has priority over the disease name, and when the treatment content is determined, the disease name is automatically determined. Therefore, by recording the actual treatment performed in the medical record, the disease name is automatically recorded, which makes the medical record preparation convenient.

[0016]

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS An embodiment in which the present invention is applied to a dental chart making support device in a dental clinic will be described in detail below. FIG. 1 is a diagram showing an outline of a hardware configuration of a system according to this embodiment. This system includes a reception CPU 1 and a medical office CPU 2, both of which are connected to each other by a signal line or the like. So-called personal computers can be used as the reception CPU 1 and the clinic CPU 2, and in this embodiment, the reception CPU 1 is set as the host and the clinic CPU 2 is set as the terminal.
How to set these hosts and terminals is arbitrary,
The reception CPU 1 may be a terminal and the clinic CPU 2 may be a host.

The receiving CPU 1 has a keyboard 3 for inputting various data and operation signals, a display 4 for displaying file contents and various data, and a printer 5 for printing medical records, bills and the like. Are connected. A keyboard having various keys such as a character data input key, a numerical data input key, a function key, and a command key is used as the keyboard 3 that functions as a data input device to the reception CPU 1. It is also convenient if a handwriting input unit or an input unit such as a so-called mouse is provided.

As the display 4, a CRT display or a liquid crystal display can be used. Preferably, a transparent so-called touch switch sheet is arranged on the display surface of the display 4, and if the touch switch sheet 6 can also input data, it is convenient. The printer 5 is preferably an electrophotographic laser printer capable of recording not only characters and numerical values but also pictures (figures) described later. The reception CPU 1 is further connected to a work memory 7 required when the CPU 1 executes a processing operation.

A keyboard 8, a display 9 provided with a touch switch sheet 11, a printer 10 and a work memory 12 are also connected to the clinic CPU 2. The configurations, functions and the like of the keyboard 8, the display 9, the printer 10 and the work memory 12 are the same as those connected to the reception CPU 1 described above. A hard disk 13 for storing necessary data and a floppy disk drive 14 for a floppy disk for storing a medical chart file to be described later are further connected to the reception CPU 1.

The data stored in the hard disk 13 includes various data files and correspondence tables. The data files include menu screen files, visit registration files, site registration files, treatment selection files, settlement files, X-ray screen files, anesthesia screen files, oral surgery screen files, prosthetic screen files, medication screen files, and tooth top-bottom deployment. It contains a picture file, a picture of the left and right teeth, and a denture picture file. The correspondence table includes a treatment-to-illness name table showing a correspondence relation between treatments and disease names, and a treatment-to-medical score table showing relations between medical care contents and points defined by insurance medical care regulations.

A floppy disk is mounted on the floppy disk drive 14, and medical chart data is stored in the mounted floppy disk. By storing the medical record data on a floppy disk, the number of patients can be increased. In addition, management is convenient if the medical record data is stored in a floppy disk that is different for each patient type (for example, medical insurance patient, non-health care patient, male patient, female patient, adult patient, pediatric patient, etc.).

In the system of this embodiment, as described above, the reception CPU 1 functions as a host. Therefore, when the clinic CPU 2 accesses the hard disk 13 and the floppy disk of the floppy disk drive 14, the reception CPU 1 is used. Done through. The hardware configuration of the system shown in FIG. 1 is merely an example. For example, a hard disk or another memory device may be connected to both CPUs 1 and 2, or another configuration may be adopted.

FIG. 2 is a development view showing the relationship between a plurality of data files stored in the hard disk 13.
The plurality of data files are organized in a hierarchical structure so that the CPUs 1 and 2 can easily access them. In particular,
The menu screen file is positioned at the highest level file, and by opening the menu screen file, the visit registration file, the site registration file, the treatment selection file, and the settlement file can be read. Further, when the treatment selection file is opened, the X-ray screen file, anesthesia screen file, oral surgery screen file, prosthetic screen file and medication screen file can be selectively read. In addition, the oral surgery screen file is provided with lower and upper developed picture files of teeth and left and right developed picture files of teeth as lower level files. The prosthetic screen file is provided with a denture picture file.

Next, of the data files, the contents of the files related to the features of this embodiment will be described with reference to specific examples. FIG. 3 shows the contents of the menu screen file. When the menu screen file is opened, the contents shown in FIG. 3 are displayed on the display. That is, “Visit registration, site registration, treatment selection, and settlement” are displayed. When a desired display content is selected by an operator, a dentist or the like, a file having that content is opened next. The selection of the display content is performed, for example, by moving the cursor displayed on the screen to the desired display content and pressing a predetermined key on the keyboard or clicking a mouse button. Alternatively, as described above, the display 4,
When the touch switch sheets 6 and 11 are provided on the display surface of 5, the content may be selected by pressing on the desired display content.

FIG. 4 shows the contents of the treatment selection file. When the treatment selection file is read from the hard disk 13 and opened, the contents shown in FIG. 4 are displayed on the display.
The treatment selection file lists a plurality of treatments performed in the dental clinic. That is, "inspection, X-ray, anesthesia, filling, endodontic treatment, periodontal treatment, oral surgery, prosthesis, addition, guidance, home medical treatment, medication" are displayed. These treatments are examples, and treatments other than those shown here may be included.

FIG. 5 shows the contents of the X-ray screen file. This file includes, for example, "simple imaging" and "tomographic imaging", and specific imaging items are displayed so that more detailed content selection can be made for each imaging. FIG. 6 shows the contents of the anesthesia screen file. In the anesthesia screen file, type of anesthesia, for example, "Transmission anesthesia""Infiltrationanesthesia"
"Pressure anesthesia" etc. and the anesthetic used for each anesthesia are displayed. A dentist or the like looks at this screen and selects anesthesia and an anesthetic suitable for the patient.

FIG. 7 shows the contents of the oral surgery screen file. The oral surgery screen file lists the oral surgery procedures performed in a dental clinic or the like. It is preferable that these treatments include all oral surgery treatments necessary in a dental clinic or the like. Further, in the oral surgery screen file, in addition to the display contents shown in FIG. 7, although not displayed, specific surgical procedures for each treatment are also registered. For example, in the case of the treatment of “implanted tooth extraction”, as the corresponding operation method, the operation method “removal of dislocation by a crown after division of the crown and removal of the buccal alveolar bone” is registered. Therefore, as will be described later, when the “implanted tooth extraction” is selected as the treatment, the “implanted tooth extraction” is recorded in the medical record, and at the same time, the above-mentioned operation method corresponding to the treatment is also recorded.

FIG. 8 shows the contents of the prosthesis screen file.
The "prosthesis" is a treatment for treating so-called false teeth (dentures). The prosthesis screen file lists the treatments for treating dentures, and the treatment performed on the patient is selected from these. FIG. 9 shows the content of the medication screen file. The medication screen file contains a list of drugs required for treatment. The drug list is organized according to use or efficacy, and the amount used once is also recorded.

When each of the above screen files is displayed on the display, if the file contents are large, it may not be possible to display them all at once. In such a case, the display content on the display may be scrollable, for example. FIG. 10 shows the contents of the tooth top and bottom development picture file. The picture inside the central frame in FIG. 10 is the picture registered in the file. Since the number and arrangement of teeth in an adult are fixed, a picture of teeth lined up in the upper jaw and a picture of teeth lined up in the lower jaw are shown in a vertically expanded state. One of the features of this embodiment is that a file in which such a picture is stored is provided in advance, and a necessary portion of this picture can be read out when a dental chart is created as described later. .
That is, when recording an oral surgical procedure, the picture containing the tooth to be treated is read. In the case of this embodiment, four parts are selectively read out: the upper right half tooth, the upper left half tooth, the lower right half tooth and the lower left half tooth.

FIG. 11 shows the contents of the tooth left and right development picture file. In this file, a picture in which the teeth are developed left and right in a so-called panoramic shape is registered as shown in the figure. When making a record of oral surgery on a dental chart, the teeth to be treated,
Two teeth before and after that are read out in principle. In the case of so-called unfamiliarity, since it is the most extreme, it does not correspond to two front and rear teeth.

In FIG. 11, the picture in the central frame is the picture registered in the file, and as shown by the broken line arrow,
When the tooth to be treated is designated, the tooth to be treated and two teeth before and after the tooth are read out from this file, displayed, and recorded in the dental chart. Although the tooth painting file data of FIGS. 10 and 11 are shown only for adults, it is preferable that the tooth painting file data of a child is also registered as file data.

When creating a dental chart, it is necessary to show the teeth to be subjected to oral surgery treatment and the teeth in the vicinity thereof, and also to show what treatment was performed. However, it takes a lot of time and effort to fill in the medical chart with the tooth to be treated and the teeth before and after it. Therefore, in this embodiment, as will be described later in detail, the tooth image is registered in advance in a file, and the tooth for oral surgery and the teeth before and after the tooth are automatically read and recorded in the chart. I did it. By doing this, the dentist need only write the patient's symptoms, incision line, suture line, etc. in the displayed tooth picture, and it is very easy and quick to create a chart including the tooth picture. Can be done in time.

FIG. 12 shows a part of the contents of the denture picture file. The "prosthesis" procedure requires a denture. By displaying in the chart what the denture looks like and what kind of adjustment was made to the denture, the contents of the medical treatment are always clear. Writing a picture of a denture on a chart is a relatively cumbersome task. Therefore, in this embodiment, a commonly used denture is registered in a file in advance so that a picture of the denture to be used can be read from the file as needed.

In the denture picture file, more denture pictures are actually registered in the file. FIG.
Indicates a part of the treatment vs. disease name table stored in the hard disk 13. One of the characteristics of dental care is that the correspondence between treatment and disease name is clear. In other words, if the disease name is known, the treatment for that disease name is decided. On the contrary, this means that if the treatment for a patient is known, the disease name of the patient can be known. Therefore, when the dentist decides on the treatment, it is preferable to be able to support the chart creation so that the disease name corresponding to the treatment is automatically entered in the chart. In the system of this embodiment, the disease name is automatically recorded in the medical record when the treatment is specified. As data necessary for this purpose, the treatment / disease name table shown in FIG. 13 is registered in the hard disk 13 (see FIG. 1).

FIG. 14 shows a part of the medical treatment score table. When conducting insurance medical treatment, dentists, etc. must submit a statement of medical treatment remuneration to a prescribed insurance institution and claim insurance medical treatment costs. It is necessary to enter the points stipulated in the insurance medical care regulations for each medical care content in this medical treatment remuneration statement. Preparation of such a medical treatment remuneration statement is complicated, and if there are omissions of points, an appropriate medical treatment remuneration will not be returned. Therefore, in this embodiment, when a medical record is created, the score for each medical care content is recorded so that the medical fee statement can be created almost automatically based on the medical record data. As data necessary for that purpose, the medical treatment score table shown in FIG. 14 is stored in the hard disk 13 in advance.

Next, various operations of the system shown in FIG. 1 will be described with reference to a flowchart showing processing contents. FIG. 15 shows a flowchart of the visit registration process. When the patient visits the hospital, the patient is registered at the reception. This registration is performed by the reception operator from the keyboard 3 connected to the reception CPU 1. The process of this visit registration will be described with reference to FIGS.
Will be described with reference to.

In this process, "visit registration" is selected from the menu screen displayed on the display 4. Then, the visit registration file among the data files of the hard disk 13 is read by the receiving CPU 1, and a display screen for selecting new patient registration or reexamination registration is displayed on the display 4 (step S11). The reception operator selects the display of "new patient" displayed on the display 4 with a cursor, for example, when a new patient is present, and selects the return visit display with a cursor when "review". In response to this, the reception CPU 1
Thus, it is determined whether it is a new patient input or not (that is, a return visit input) (step S12).

If it is a new patient input, a screen for registering patient data is displayed on the display 4. The reception operator inputs the examinee's name (patient name), date of birth, address, insurance policy number, insurance type, etc. from the keyboard 3 according to this display screen. When data entry is complete, reception CP
The input patient data is registered by U1, and chart data is created (step S13). At this time,
In the medical chart data, “first visit” is recorded as the medical record, and in the case of insurance medical treatment, the initial medical examination score is recorded (steps S14 and S17). Specifically, the reception CPU 1 searches the medical treatment score table recorded in the hard disk 13 and reads the score of “first examination”. Then, the read score is recorded in association with the “first visit” of the medical record data.

On the other hand, in step S12, if it is determined that there is no new illness, that is, reexamination, there should be a medical record of the visiting patient, so the medical chart data of the visiting patient is retrieved from the medical chart file and read out. (Step S15). The date of the visit and "revisit" are recorded in the medical record data. Further, the medical treatment score table of the hard disk 13 is searched, and the re-examination score is read,
It is recorded in the medical record data (steps S16, S
17).

After that, both in the case of a new patient and in the case of reexamination, the medical chart data of the patient is stored in the work memory 7 because it is used for treatment (step S18). next,
The part registration will be described according to the flow of FIG.
“Registration of a site” is a process of recording a treatment target site in a medical record. The site registration is usually performed based on an inquiry or confirmation of the intraoral condition when the dentist starts medical treatment for the patient.

The dentist or the like who has grasped the treatment area operates the keyboard 8 to select "Registration" on the menu screen (see FIG. 3). In response to this, the examination room CPU 2 reads the site registration file from the data file of the hard disk 13 via the reception CPU 1. Then, the site disease name input screen is displayed on the display 9 (step S21).

This screen is, for example, a screen as shown in FIG. That is, the part, the disease name, the medical treatment start date, the medical treatment end date, and the tooth layout diagram are included, and the numbers (or symbols) that identify each tooth are written in the diagram. The dentist or the like fills in the "site" of the site disease name input screen displayed on the display 9 with the number (or code) of the tooth to be treated, which is shown in the tooth layout diagram.

FIG. 23 shows an example of entry of the parts. FIG. 23
(A) shows that the right 8th tooth of the lower jaw (so-called unfamiliar) is the treatment target. FIG. 23B shows that the second upper jaw tooth (side incisor) is the treatment target. FIG. 23 (c) shows that 14 teeth from the right side 7th to the left side 7th of the upper jaw are to be treated. Figure 2
3 (d) are "7, 6, 5, 4" on the left and right of the lower jaw respectively.
Represents that the tooth of the subject is to be treated.

As described above, in the site registration, the tooth to be treated is specified by entering the tooth number in each quadrant divided into four quadrants by the cross line. This is a convention in dental charts. In addition, in the layout of FIG. 22, the teeth denoted by A to E shown inside are milk teeth, and when treating milk teeth of an infant or the like, the parts are identified by symbols A to E. Done.

Returning to FIG. 16, the site input for specifying the tooth to be treated is performed by the keyboard 8, for example. When the site is input from the keyboard 8, the doctor's office CPU 2 determines that the site is input (step S22). Then, the input part is registered as medical record data (step S23). Further, the CPU 2 automatically registers the medical treatment start date (step S24).

Next, the treatment selection process will be described. In the actual practice of dental treatment, in the case of a new case, after the site registration, an X-ray photograph of the tooth is taken, and the treatment content is determined with reference to the X-ray photograph. Then, anesthesia is applied to the treatment site, and treatment, that is, oral surgery is performed. Alternatively, a denture that fits the patient's mouth is created. And the necessary medicine is given to the patient. In parallel with the treatment, the dentist records a medical record in the medical record.

Next, a procedure for creating a medical record of a medical record by the apparatus according to this embodiment will be described based on a specific medical example. The explanation is based on four specific cases. Case 1: Extraction of the right lower third third molar (Exclusion of the lower right parent unknown) Case 2: Removal of the root cyst of the right incisor Case 3: Wearing a full denture Case 4: Wearing a free end denture Take for example.

In the case of case 1, the medical care contents recorded in the medical record are, for example, the contents shown in FIG. Ie April 1
The first medical examination was accepted on the 4th, and after X-ray photography, anesthesia and gingival incision were performed to extinguish the swelling of the gums, and given medicines were given. On April 18, a re-examination was received, and unexplained tooth extraction buried in the gums, that is, impacted tooth extraction is performed. And the prescribed medicine is given. Furthermore, on April 19th, the next day, the patient was re-examined and was examined for cleaning and the subsequent process. The medical treatment for Case 1 is over.

Using the system of this embodiment, FIG.
The medical records of the medical records shown in are almost automatically recorded. In particular, the tooth paintings on April 14th and on April 18th are also recorded automatically with the aid of a computer device. Therefore, a dentist or the like can easily and easily record the contents of medical treatment in the chart of the patient while performing medical treatment. Especially, since the picture of the tooth is recorded automatically,
It is possible to clearly indicate what kind of treatment was specifically performed.

A method of creating medical chart data will be specifically described below with reference to the contents of the medical chart shown in FIG. 24 in accordance with the flow chart of the treatment selection processing shown in FIGS. When “procedure selection” in the menu screen displayed on the display 9 is selected, the treatment room CPU 2 reads the treatment selection file from the data file of the hard disk 13, and the display 9
A selection screen is displayed on the screen (step S31). This treatment selection screen is a screen in which many treatments shown in FIG. 4 are listed. The dentist or the like selects a treatment performed on (or will be performed on) the patient from the treatments. In this example,
First, "X-ray" is selected. The selection operation is performed using the keyboard 8 like other operations.

When the treatment room CPU 2 determines that the treatment selection signal is input (step S32), the X-ray screen file selected from the data file of the hard disk 13 is read according to the inputted treatment selection signal. (Step S33). Then, it is displayed on the display 9 (step S34). This display screen has the contents shown in FIG. 5 described above. The dentist or the like selects an imaging method from the X-ray screen file. For example, a “panoramic X-ray photograph” (so-called panoramic photograph) of tomography and a “standard type” (so-called dental photograph) of simple photography are selected. This selection is also made using the keyboard 8.

When the input of the selection signal is discriminated by the CPU 2 for the medical office (step S35), the content of the selected treatment, in this case, the panoramic photograph and the dental photograph are selected is displayed on the display 9 (step S35). S3
6). Then, the selected contents are registered in the work memory 12 as medical record data (step S37). When the dentist or the like wants to change the selected content or selects the wrong treatment, he / she inputs a cancel signal by using, for example, a cancel key on the keyboard 8. On the CPU2 side,
When this cancel input is determined (step S38), the procedure registered in step S37 is canceled (step S39),
Returning to step S34, the contents of the X-ray screen file shown in FIG. 5 are again displayed on the display 9.

Next, proceeding to FIG. 18, if there is no cancel input, etc., the CPU 2 for the medical office uses the hard disk 1
The medical treatment score table of No. 3 is searched (step S4
0), the score corresponding to the content registered in step S37 is read. That is, if there is a score corresponding to the content registered in the work memory 12 in step S37, the score is recorded in association with the registered content (step S4).
1, S42). If no insurance score is set in the registered content, the score registration process of step S42 is not performed.

Then, in step S43, it is determined whether or not the contents registered in step S37 are oral surgery procedures. In this example, since X-ray imaging has been registered, step S43 is NO, and the process proceeds to step S46. In step S46, it is determined whether the registered content is a prosthetic treatment. Also in this determination, since it is determined as NO, the process proceeds to step S50 of FIG.

In step S50, the registered contents stored in the work memory 12 are displayed on the display 9. This display is the portion A in FIG. The dentist or the like who has confirmed the registered contents by the display inputs a confirmation signal from the keyboard 8. The examination room CPU 2 determines that the confirmation signal is input (step S52). Then, an inquiry as to whether or not to print the medical record is displayed on the display 9 (step S52). At this stage, since the medical chart printing is not performed, it waits for a signal input indicating that the medical chart printing is not performed (step S53). Then, the process returns to step S31 of FIG.

In step S31, the treatment selection screen shown in FIG. 4 is displayed again, and "anesthesia" is selected as the next treatment. In accordance with this selection, the clinic CPU 2 reads the anesthesia screen file from the hard disk 13 and displays the contents on the display 9 (steps S32, S).
33, S34). This display screen has the contents shown in FIG. 7, for example, and the dentist or the like selects the contents of the anesthesia applied to or about the patient. In this example, "infiltration anesthesia" is selected and "xylocaine" is selected as the anesthetic. In response to this, the clinic CPU 2
The selected content is displayed on the display 9 (step S36), and the selected content is registered in the work memory 12 (step S37). The display content is the content of B of FIG. If there is no cancel input, the score corresponding to the registered content is retrieved from the medical treatment score table, and the score is also registered in the work memory 12 (step S40-).
S42).

In this case as well, the registered content is neither an oral surgery procedure nor a prosthesis procedure, so the processing in the clinic CPU 2 is performed in steps S43 → S46 → S50 → S51 → S.
The process proceeds to 52 → S53 → S31. In the next treatment selection, “oral surgery” is selected from the treatment selection screen shown in FIG. 4, and the screen shown in FIG. 8, for example, is displayed (step S
31, S32, S33, S34).

The dentist or the like selects, from the various treatments listed on the oral surgery screen, the treatment performed on the patient or the treatment to be performed, that is, "incision (gingiva)" in this example. The selected treatment is displayed in step S36 and registered in step S37 in the same manner as described above. Also,
The score corresponding to the selected treatment is read and the score is also registered (steps S40 and S42).

Next, in step S43, it is determined whether or not the registered content is an oral surgery procedure. In this case, since it is an oral surgery procedure, the processes of steps S44 and S45 are executed. That is, in the case of oral surgery, the "site registration data" registered as the medical record data is read (step S44). In this example, the part registration data has the content shown in FIG. Based on the read site registration data, the location of the site for the oral surgery procedure is specified. As a result, the corresponding partial picture is read from the tooth top and bottom development picture file and / or the tooth left and right development picture file recorded in the hard disk 13. Specifically, the picture of the tooth on the right side of the lower jaw is read from the upper and lower developed picture file of the tooth shown in FIG.
Further, from the left and right developed image file of the tooth shown in FIG. 11, a picture for two teeth before and after the tooth designated by number 8 designated by the site registration is read. However, in the case of this example, the tooth registered as the part is the 8th tooth and the endmost tooth, so that tooth and the previous 3 teeth are read.

Then, the read partial picture of the tooth is displayed together with the chart data registered in steps S37 and S42 (step S50). The dentist, etc., sees the displayed contents, deletes unnecessary pictures, and adds necessary symptoms and contents of treatment. The display after the contents are added is the portion C in FIG. In this display, swelling (+) and tenderness (+) and the location thereof are added to the upper and lower developed pictures of the tooth. In addition, an incision line was made to make pus.

It is preferable that the symptoms, treatment lines, etc. of the patient to be added in association with these displayed pictures are added by handwriting while watching the pictures displayed on the display 9. For example, if the keyboard 8 has a handwriting input function, the symptoms and treatment lines of the patient can be written by handwriting input. Alternatively, when a transparent touch switch sheet 11 is arranged on the surface of the display 11, the sheet 11 can be used for writing.

After that, when the content of the oral surgery procedure is confirmed, the process proceeds to steps S52 → S53 → S31 again, and the content of the medication is then recorded in the medical chart. That is, the medication screen file is read in step S33, and the screen is displayed on the display 9 (step S34).
The medication screen is, for example, the screen shown in FIG. 9, and includes a drug list. The dentist or the like selects a medicine from this medicine list. In response, the medicine selected by the CPU 2 is registered (step S37), the score of the registered content is also registered (step S42), and the registered content is displayed on the display 9
Is displayed (step S50). This display is the content of D in FIG. The dentist or the like sees this display and subscribes the patient to the required amount of medicine to be given on the day.

When the recorded contents are finally confirmed, the processing is completed and the medical record data is stored in the floppy disk. Note that, in the above description, the contents displayed in step S50 are the portion A of the medical examination contents of the chart of FIG.
It has been explained that the portion, the portion C, and the portion D are displayed respectively. However, instead of such a display, when the part A is displayed, the “first visit” recorded before that is displayed.
The part "170" of E may be displayed together. Similarly, when the portion B is displayed, the portions E and A may be displayed together. Further, when the C portion is displayed, the E, BA, and B portions may be displayed together. Furthermore, when the D portion is displayed, the E, A, B, and C portions may be displayed together.

Further, as shown in step S53 of FIG. 19, it is preferable that the chart print signal can be inputted. When the input of the medical chart print signal is determined in step S53, the CPU 2 drives the printer 10 and the medical chart contents on the medical chart paper set in the printer 10,
That is, the record of April 14 of FIG. 24 is printed. The printed matter may be stored as a medical record.

If the system is not equipped with a handwriting input function or the like, the dentist or the like may handwrite the symptoms, treatment lines, and the like to be added to the partial picture of the tooth on the printed paper chart. Alternatively, the amount of medicine in the medication record may be written in the medical chart by hand. In that case, the medical record is saved as an original, and the next time the patient returns to the hospital, the medical record is set in the printer 10 and the contents after April 18 are additionally printed on the medical record. You should do so.

The medical record on April 18 shown in FIG. 24 is also recorded in substantially the same manner as the medical record on April 14 described above. Briefly, “revisit 32” is recorded by the visit registration process shown in FIG. Also, FIGS.
In the treatment selection process shown in (1), "transmitted anesthesia" and its score "38 + 9" are recorded based on the anesthesia screen file.
In addition, based on the oral surgery screen file, “implanted tooth extraction” and its specific content “distance removal after crown division and buccal alveolar bone removal” are recorded, and the score is “1”.
000 ”is recorded. Further, the partial picture of the tooth shown in the record of April 18 in FIG. 24 is automatically recorded.

A dentist or the like may add a suture line, which is the content of the treatment, and the removed portion, to this picture, and also add the content of the treatment of "three-thread suture". The April 18 dosing record will be similar to that of April 14.
Further, the recorded contents regarding April 19 of FIG. 24 will be described. The contents for April 19 are re-examination and washing. The wash is selected from the oral surgery screen file. When "wash" is selected, the contents shown in FIG. 24, that is, spontaneous pain (), percussion pain (), etc. are automatically displayed. The dentist or the like examines the symptom of the patient and, if the patient complains about any of the indications shown here, additionally writes a + symbol in ().

Next, the case 2 will be described. Case 2
Is a process for removing the root cyst of the upper right incisor. Four
On the 22nd of the month, the initial examination, the score "170", and site registration will be performed. In this case, the part registration shown in FIG. 23B is performed. Then, the content and score of the X-ray photography are registered, and the "incision (periosteum)" of the invasive anesthesia and the oral surgery procedure is registered. In connection with the registration of this oral surgery procedure, as shown in FIG.
Centering on the right upper jaw tooth 2, which is the target tooth, 2
The tooth component is read from the left and right developed images of the tooth and registered.

These registration processes are similar to those described above with reference to FIG.
The process is performed according to the flowcharts 6 to 20.
The dentist or the like additionally records the symptom “swelling (+), tenderness (+)” of the patient, the position thereof, and the incision line which is the treatment content in the registered and displayed picture. Also in this case, the tooth picture itself is automatically read out and recorded, so that only the symptoms and treatment lines of the patient need to be entered. Therefore, it is possible to record the treatment details on the chart in a short time and properly and neatly.

The recording of the medication is carried out in the same manner as in the case 1 described above. The treatment on April 25 in FIG. 25 is almost the same as the above. In the record of oral surgery procedure on April 25, when "cyst removal (crown size)" in the oral surgery screen file is selected, the procedure will be displayed.
A specific operative procedure of "remove buccal alveolar bone after mucoperiosteal detachment" is also registered.

As described above, in the oral surgery procedure, the specific surgical procedure for the procedure is determined. In this example, in the case of "cyst extraction (crown size)", the surgical procedure is performed by the surgical procedure recorded in FIG. Therefore, the surgical procedure is also automatically registered by specifying the treatment content. By doing so, it is possible to save the time and labor for the dentist or the like to fill in the medical record each time the wording indicating the routine operation is performed, and it is possible to shorten the time required to create the medical record.

If the specific technique is different from the one displayed, it may be corrected each time. Next, the case of case 3 will be described. Case 3 is a complete denture wearing procedure.
In the case of this treatment, the site registration is performed after the “first visit” and the score “170” are registered in the visit registration. In this case, the site registration shown in FIG. 23C is performed. Then, the procedure proceeds to the treatment selection, and the prosthetic screen file is read and displayed. The prosthetic screen file has the contents shown in FIG. 8, for example. The procedure performed on the patient is selected from the procedures described on this screen and registered as medical chart data.

The feature of this example is that the picture of the complete denture is recorded in the medical treatment contents on April 16. Specifically, the recording of the picture of the complete denture is performed as follows. With reference to FIG. 18, in step S46, it is determined whether or not the registered content is a prosthetic treatment, and in the case of the prosthetic treatment, the display 9 displays an inquiry as to whether or not a picture of a denture is necessary. In response to an inquiry, a dentist or the like inputs whether or not a picture is necessary. If there is an input indicating that a picture is required (YES in step S47), the part registration data is read (step S48), and the corresponding denture from the denture picture file is read based on the contents of prosthesis procedure registration and part registration. A picture is selected (step S49). Then, the content is displayed on the display 9 (step S50).

That is, the dentist or the like displays the display 9
The recorded contents on April 16 of FIG. 26 displayed in FIG. 26 are confirmed. Then, write down the adjusted parts and contents for the displayed denture picture. This content writing can be performed by the handwriting input function of the keyboard 8 or the like, similarly to the content writing in the oral surgery procedure described above. In the specific example of FIG. 26, the occlusal adjustment is performed on the two front sides of the denture, and
It is recorded that the parts were ground together.

As described above, when the denture is attached, the denture picture is entered in the chart and the adjustment contents are recorded, so that when the patient returns to the hospital, the record of the patient is correctly grasped and the next Adjustments can be made appropriately. FIG. 27 shows an example of filling in the medical record of Case 4. Case 4 is a free denture wearing procedure. Also in this case, the picture of the free denture is automatically recorded in the chart, and the adjustment portion can be added on the picture. The record on April 18 shows an example of the record.

Since the other contents are the same as those in the case 3 described above, detailed description will be omitted. By the way, in the dental chart, as shown in the “site disease name screen” of FIG. 22, in addition to the site to be treated, a field for recording the disease name is provided. According to the system of this embodiment, the recording of this disease name is also automatically performed. Next, the disease name determination and recording process will be described with reference to the flowchart in FIG.

The disease name determination process shown in FIG. 20 is preferably executed by the CPU according to a program, for example, in an appropriate idle time or periodically without waiting for an instruction input by the operator. Of course, for example, each time the treatment selection process (FIGS. 17 to 19) is completed, the disease name determination process may be executed automatically or by an operator's instruction.

In the disease name determination process, first, the data of the medical record for determining the disease name is read from the medical record file 14 (step S61), and the registered treatment content is used as an index to search the treatment-related disease name table of the hard disk 13. (Step S62). Then, when there is a disease name candidate corresponding to the treatment, the disease name candidate is once registered in the disease name column of the medical record (step S64). In this case, when there are a plurality of disease name candidates, all the extracted disease name candidates are once registered in the disease name column of the medical record. In addition,
If there is no disease name candidate in step S63, the disease name is not registered in the disease name column, and the next disease name determination process is waited for.

As described above, as a feature of dentistry, the disease name and the treatment content are closely linked.
Therefore, if a certain treatment content is known, it is easy to infer the disease name based on the treatment content. In most cases, the disease name inferred based on the treatment content is a correct disease name. Therefore, in this embodiment, a treatment name table is provided in the correspondence table of the hard disk, and the disease name for the treatment is registered in advance.

Therefore, as the description of the treatment content in the treatment section of the medical record progresses, the disease name corresponding to the treatment is gradually narrowed down. For example, taking the case 2 described above as an example, from the procedure of "incision (periosteum)", as the disease name,
The disease name candidates “AA, subperiosteal abscess, palate abscess” are obtained (see FIG. 13). Here, “AA” is an abbreviation for alveolar abscess. Therefore, in case 2, when the treatment on April 22 is completed, the above three disease name candidates are registered as disease names.

However, when the treatment progresses and the treatment of “cyst removal (crown size)” is registered on April 25, the disease candidate is narrowed down to “AA, WZ”. Here, "WZ" is an abbreviation for root cyst. If the disease name is finally 1
If not, the dentist may specify one of the disease names if it becomes “AA, WZ” as in this example.

As described above, the entry of the disease name in the dental chart is almost automatically performed. According to the system of this embodiment, when insurance medical treatment is performed, it is possible to automatically create a medical treatment fee statement to be charged to a predetermined insurance institution. Next, the process of creating the insurance medical treatment fee statement will be described with reference to the flow chart of FIG.

This processing can be performed by the operator of the reception CPU 1 between visit registrations and other times. In this process, first, the operation mode of the reception CPU 1 is switched to the mode for medical treatment statement preparation processing, and the number of the chart for which the statement is to be prepared is input from the keyboard 3. When the chart number is input (step S71), the CPU 1 searches the chart file 14 (step S72) and reads the input chart data (step S73). Of the read chart data, the part and disease name data are stored in the work memory 7
Stored in the work register 1 (step S7)
4). Further, the score data recorded in association with the treatment registration in the medical record data is stored in the work register 2 of the work memory 7 (step S75). Then, the points stored in the work register 2 are totaled, and the cost corresponding to the total points is automatically calculated (step S7).
6). The cost calculation is based on a predetermined processing program,
It is performed based on the cost calculation table stored in association with the program.

The result is displayed on the display 4. The operator who confirms the displayed contents determines whether or not to print, and when printing, inputs the fact from the keyboard 3. When the CPU 1 receives a signal to be printed (step S77), the printer 5 is driven to print data on the remuneration statement set in the printer 5 (step S78).

By the above processing, the insurance medical treatment remuneration statement can be automatically created. The above embodiments have been described with reference to a medical record creation support system in a dental clinic. However, the device of the present invention can be applied not only to dental clinics but also to medical record creation support in other medical fields.
For example, in a surgical chart creation support system,
If pictures such as bones representing fractures to be recorded in the surgical chart are registered in the data file of the hard disk beforehand,
By reading the picture, it is possible to automatically fill in the picture of the treatment site in the medical chart.

[0086]

According to the present invention, when a medical record is recorded on a medical record, the medical record can be easily recorded, and the created medical record can be effectively stored and managed. In addition, since a picture showing the treatment area is displayed on the medical chart, the treatment area and the content of the treatment can be correctly grasped.

Further, since the score in the case of insurance medical care is recorded in the medical record, it is convenient when preparing a medical treatment fee statement for insurance medical care. Furthermore, according to the present invention, a medical treatment statement of insurance medical treatment can be automatically created,
Not only management of medical records in clinics, but management related to insurance medical treatment can be performed efficiently and correctly.

[Brief description of drawings]

FIG. 1 is a block diagram showing an outline of a hardware configuration of a system according to an embodiment of the present invention.

FIG. 2 is a development view of a data file provided in the system according to the embodiment of the present invention.

FIG. 3 is a diagram showing an example of contents of a menu screen file in a data file.

FIG. 4 is a diagram showing an example of contents of a process selection file in a data file.

FIG. 5 is a diagram showing an example of contents of an X-ray screen file in a data file.

FIG. 6 is a diagram showing an example of contents of an anesthesia screen file in a data file.

FIG. 7 is a diagram showing an example of contents of an oral surgery screen file in a data file.

FIG. 8 is a diagram showing an example of contents of a prosthetic screen file in a data file.

FIG. 9 is a diagram showing an example of contents of a medication screen file in a data file.

FIG. 10 is a diagram showing an example of the contents of the tooth top-bottom development picture file in the data file and how to extract the partial picture of the tooth in relation to it.

FIG. 11 is a diagram showing an example of the content of a left and right developed picture file of teeth and a specific example of how to extract a partial picture of a tooth.

FIG. 12 is a diagram showing an example of contents of a denture picture file.

FIG. 13 is a diagram showing an example of the contents of a treatment vs. disease name table.

FIG. 14 is a diagram showing an example of contents of a medical treatment score table.

FIG. 15 is a flowchart of a visit registration process.

FIG. 16 is a flowchart of a part registration process.

FIG. 17 is a flowchart (part 1) of treatment selection processing.

FIG. 18 is a flowchart (part 2) of treatment selection processing.

FIG. 19 is a flowchart (part 3) of treatment selection processing.

FIG. 20 is a flowchart of a disease name automatic determination process.

FIG. 21 is a flowchart of insurance medical treatment fee statement preparation processing.

FIG. 22 is a diagram showing an example of a site disease name screen.

FIG. 23 is a diagram showing an example of entry of a site on a site disease name screen.

FIG. 24 is a diagram showing the contents recorded in the medical record in case 1;

FIG. 25 is a diagram showing the contents recorded in the chart in case 2;

FIG. 26 is a diagram showing the contents recorded in the medical record in case 3;

FIG. 27 is a diagram showing the contents recorded in the chart in case 4;

[Explanation of symbols]

 1 CPU for reception 2 CPU for medical office 3,8 Keyboard 4,9 Display 5,10 Printer 7,12 Work register 13 Hard disk 14 Floppy disk drive

Claims (5)

[Claims] 1. A storage means in which a picture representing a tooth arrangement including a predetermined number of teeth is stored, and a tooth corresponding to the treatment data from the picture stored in the storage means according to given treatment data. Read-out means for reading out a partial picture including, holding means for holding the read-out partial picture in association with given treatment data, and treatment data and a partial picture held in the holding means for a medical chart sheet. A dental chart creating support device comprising: a recording unit that records at a predetermined position. 2. Storage means for storing a plurality of denture pictures, and reading means for reading out a picture corresponding to the treatment data among the denture pictures stored in the storage means in accordance with given treatment data. Holding means for holding the read-out picture in association with the given treatment data, and recording means for recording the treatment data and the denture picture held in the holding means at a predetermined position on the medical chart sheet. An apparatus for supporting the creation of a dental chart, which includes: 3. A storage means storing a plurality of types of pictures of a part of a human body to be treated, and a picture corresponding to the treatment data among the pictures stored in the storage means according to given treatment data. Read-out means for reading out, the holding means for holding the read-out picture in association with the given treatment data, and the record for recording the treatment data and the picture held in the holding means at a predetermined position on the medical chart sheet A medical record creation support apparatus comprising: 4. A medical care content point score storage means in which a relationship between medical care content and points determined by insurance medical care regulations is recorded, and when the medical care content to be recorded in a medical record is given, the storage means is searched, When a score is set for a given medical care content, a reading means for reading the score and a recording means for recording the score read by the reading means in a medical record in association with the given medical care content are provided. A medical record creation support device characterized by including. 5. A treatment-to-disease name storage means in which a plurality of treatments and disease name candidates predicted from each treatment are stored, and a treatment storage means to store the given treatments when the treatments to be recorded in the medical record are given. , Reading means for searching the treatment vs. disease name storage means based on the treatment stored in the treatment storage means, and reading out a disease name candidate predicted from the treatment, and a disease name candidate read out by the reading means. Holding means for holding as a disease name to be recorded in the chart, the reading means, when a new treatment is additionally stored in the treatment storage means, based on a plurality of treatments including the additionally stored treatment, By searching the treatment vs. disease name storage means,
It is a reading means for reading out a disease name candidate satisfying all the treatments, and the holding means updates the held disease name with the disease name candidate read out by the reading means. Support device.