JP6849296B1 - Electronic medical record - Google Patents

Abstract

PROBLEM TO BE SOLVED: To provide an electronic medical record and a method of using the electronic medical record, which can shorten the entry time for the medical record. SOLUTION: The electronic medical record is a finding area constituting a main complaint area (W1a, W1b, W1c) for inputting a patient's main complaint obtained by an interview and a finding input field for inputting an examination finding obtained by the examination. It has W1d and a function selection window K in which a GUI in which a function for generating the chief complaint area and the finding area is set is arranged. The chief complaint area is input as a chief complaint pattern window W1a configured so that input can be performed using a standard format, a text window W1b capable of text input using a keyboard, and image information by description / drawing using a touch pen. It is composed of a possible image window W1c. When the GUI that generates the main complaint area is selected, each window is generated at the same time. [Selection diagram] FIG. 8

Description

The present invention relates to an electronic medical record.

Medical expenses paid to doctors by the National Health Insurance, etc. are paid based on the claims from the doctors to the insurer, the Social Insurance Medical Fee Payment Fund, the National Health Insurance Association, and other examination and payment institutions.
The examination and payment institution examines the request from the doctor and decides whether or not to pay, but in the past, this request was made in writing. In recent years, various improvements have been made so that processing can be performed electronically from the viewpoints of labor saving, speeding up processing, and paperlessness, and doctors are also required to use electronic medical records and claim medical fees based on electronic medical records. Is encouraged.

The electronic medical record includes, for example, the one described in Patent Document 1. The matters to be stated in the medical record are stipulated by law and must be stated for each patient for each examination. For example, the medical record must accurately describe the complaint, doctor's findings, disease name and severity evaluation, treatment policy, medication, and other treatment details.
However, in the case of a practitioner called a town doctor or a cold doctor, the number of patients that one doctor must see may reach 200 to 300 or more per day during an epidemic period such as a cold or influenza. In this case, about 30 people must be examined per hour, and the above-mentioned matters must be described in the medical record for each examination. To put it simply, one medical record must be written in 2 minutes, and in these 2 minutes, the chief complaint is heard, findings are formed, and the treatment policy is decided based on the identification of the disease name and the evaluation of the severity. , The necessary measures must be taken.

Japanese Unexamined Patent Publication No. 2017-162037

As mentioned above, the items described in the medical record are indispensable for billing medical expenses to laws and regulations and examination and payment institutions, and must be clearly described in detail. However, since the consultation time that can be assigned to each patient is extremely short except in special cases, if it takes time to fill out the medical record, the consultation time per patient will increase as a result. In addition, since the time to listen to the complaint while looking at the patient's face is reduced, it constitutes a cause of dissatisfaction with the doctor.
The present invention has been invented in view of the above circumstances, and an object of the present invention is to provide an electronic medical record and a method of using the electronic medical record, which can shorten the entry time for the medical record.

In addition, medical records using conventional paper are basically created by handwriting, and have the advantage of being able to list the entire spread. If you are an experienced doctor, you can visually (image) the described information and grasp the contents instantly, which has an element that leads to shortening of the examination time. The present invention can efficiently create medical records in a short time even in a clinic with a large number of visiting patients, in which one doctor has to deal with each day without losing the advantages of such paper. The challenge is to provide electronic medical records.

In order to solve the above problems, the present invention has the following configurations. That is,
An arithmetic processing means having a CPU for executing a program, a display for displaying an image by executing the program, an electronic medical record having a keyboard and a touch pen for inputting information and operation instructions.
A main complaint area for displaying the main complaint of the patient obtained by the interview arranged on the medical examination information input window displayed on the display, a finding area for displaying the medical examination findings obtained by the medical examination, and the main complaint area are generated. It has a function selection window in which a GUI with a function to be set and a GUI with a function to generate a finding area are arranged.
The complaint area includes a complaint pattern window that displays the complaints recorded using a standard format or a standard format in which information about the complaint is represented by an image, a text window that allows text input using a keyboard, and a text window. It has an image window that is displayed as editable image information by writing and drawing with a touch pen, and the chief complaint pattern window, text window, and image are accompanied by the operation of the GUI in which the function to generate the chief complaint area is set. An electronic chart characterized by being configured to generate windows at the same time.

In addition, the electronic medical record according to the present invention has the following configuration in the above invention. That is,
It has an edit editor function for editing the complaints recorded using the standard format or the standard format displayed in the complaint pattern window.
The editing editor function is characterized in that it is configured to be activated by selecting and instructing a standard format or a standard format recorded in the main complaint area.

In addition, the electronic medical record according to the present invention has the following configuration in the above invention. That is,
It has an edit editor function that records the chief complaint using the standard format displayed in the chief complaint pattern window that is activated by selecting the GUI that sets the function to generate the chief complaint area, and at the end of the edit editor function. Along with this, it is characterized in that it is configured to generate the chief complaint pattern window, the text window, and the image window.

In addition, the electronic medical record according to the present invention has the following configuration in the above invention. That is,
It has an editing editor that is activated by selecting a GUI that has a function to generate the finding area, and the editing screen by the editing editor function is selected from a plurality of pre-registered finding input formats formed as image information. It is composed of one finding input format and an input layer displayed on top of the selected finding input format, and an image in which the finding input format and the layer are combined is displayed on the medical examination information input window. It is characterized by being configured.

In addition, the electronic medical record according to the present invention has the following configuration in the above invention. That is,
The medical examination information input window is arranged substantially in the center of the display screen constituting the electronic medical record, and is also arranged.
The chief complaint pattern window, the text window, and the image window constituting the chief complaint area in the medical examination information input window are arranged downward in the order.

In addition, the electronic medical record according to the present invention has the following configuration in the above invention. That is,
The text window and the image window are characterized in that they are automatically deleted from the medical examination information input window when the information is not input.

In addition, the electronic medical record according to the present invention has the following configuration in the above invention. That is,
The finding input format is composed of an image file consisting of graphic information representing a part of the human body as an illustration and text information listing physical findings that may occur in the part of the human body represented as the illustration. It is characterized by that.

In addition, the electronic medical record according to the present invention has the following configuration in the above invention. That is,
The editor function can generate a plurality of pre-described findings-described formats in which the findings expected at the time of medical examination are described in the above-mentioned findings input format in advance.
It is characterized in that the created findings-described format is displayed in a selectable list together with other findings input formats and can be read into the findings area.

The electronic medical record according to the present invention simultaneously generates three input windows having different functions as the chief complaint area generated on the screen, and can quickly record the complaint claimed by the patient. Moreover, it is possible to instantly select and input an appropriate input window according to the content of the complaint. This has the effect of significantly shortening the time for inputting information to the electronic medical record and enabling efficient recording. In addition, this makes it possible to effectively use the dialogue and consultation time with patients who should spend time within the limited consultation time, and it is possible to provide high-quality medical treatment services and enhance the contents of medical record information. It has the effect of being able to make it.

It is explanatory drawing which showed the flow of the medical examination performed while using an electronic medical record. It is explanatory drawing of the main window. It is explanatory drawing of the function selection window. It is explanatory drawing which showed an example of the edit editor screen which edits a chief complaint pattern. It is explanatory drawing of the state which read the chief complaint pattern diagram in the chief complaint area. It is explanatory drawing of the state which the list of the finding pattern diagram is displayed in the main window. It is explanatory drawing of the finding pattern figure displayed in a list. It is explanatory drawing of various areas expanded in the medical information entry window. It is explanatory drawing of the finding pattern figure expanded and displayed on the edit screen. It is explanatory drawing which showed the other example of the finding pattern diagram.

The electronic medical record according to the present embodiment is composed of a computer and a program executed by the computer. A computer is composed of arithmetic processing means composed of a CPU or the like for executing a program, an output device such as a display for outputting a program execution result, and various input devices for inputting information and operation instructions. The optimum input device in the present embodiment is a pen-type input device such as a touch pen that can input using a tablet board or a touch-type screen, a keyboard, a mouse, and the like. The detection method of the touch pen may be any method such as a pressure sensitive method and an electrostatic detection method. Although data of various medical devices can be imported, the description thereof will be omitted in this embodiment.

The medical record records various information such as the patient's complaint, current medical history, medical examination findings, diagnosis, treatment policy, instruction content, disease name and its outcome, etc. entered by the medical staff, and is used for billing medical fees. It constitutes the receipt to be used and the information required to create the receipt.
The electronic medical record according to the present embodiment records the above-mentioned various information and displays information such as characters, symbols, images, and videos on a display in a format that looks like a medical record. is there. It also has an order entry function such as inspection order, prescription, image / inspection result reference, a function to output information necessary for creating the above-mentioned receipt, and a medical accounting function.

FIG. 1 is an explanatory diagram showing a flow of a medical examination performed while using an electronic medical record in the present embodiment. In clinics where patients often visit and receive medical examinations, the medical examination begins when the doctor listens to and records the chief complaint while facing the patient in the examination room (step St1). The chief complaint is a medical condition or physical condition obtained by explanation from the patient or an attendant, changes over time in the medical condition, and other information necessary for diagnosis. The content of this complaint is legally stated in the medical record.

FIG. 2 shows the main window W0 of the electronic medical record displayed on the display. The electronic medical record has a main window W0 displayed on the screen of the display, and various windows (areas) generated in the main window W0 are used to input and display various information. ing. A medical examination information input window W1 is arranged substantially in the center of the main window W0. In the medical examination information input window W1, several input windows (W1a, W1b, W1c) having different functions capable of inputting (recording) the main complaint as the main complaint area are generated.
For the record of the chief complaint, the chief complaint pattern window W1a, which records using the standard format in which the recorded items are posted in advance or the pre-filled format in which a part of the main complaint is entered in advance, and the free description that does not depend on the standard format are described. It is done using windows that can be done (W1b, W1c). Further, the free description can be performed using the text window W1b for input by typing on the keyboard and the image window W1c for input by description / drawing using the touch pen.
The input windows (W1a, W1b, W1c) are arranged in a predetermined order in the medical examination information input window W1 arranged substantially in the center of the main window W0, and the details will be described later.

After filling in the chief complaint, the doctor's medical examination findings (hereinafter, also simply referred to as "findings") are entered in the electronic medical record (step St2). The medical examination findings are various information obtained by the medical examination, such as the medical condition and the basis of the diagnosis, and can be necessary information for judging or evaluating the treatment policy and suitability. The doctor's examination is performed, for example, to confirm the presence or absence of the underlying findings in order to narrow down the probable disease group from the disease groups that can be assumed and listed from the chief complaint. In addition, in consideration of the possibility that an unexpected disease has occurred, observation of each part of the body necessary for confirming the possibility is performed. Furthermore, it is also possible to obtain the findings of each part of the body necessary for follow-up of the disease whose diagnosis name has already been confirmed, and to confirm the presence or absence of multiple findings necessary for differential diagnosis and evaluation of the medical condition. ..
When writing down the medical examination findings, it is now possible to draw sketches of each necessary body part and record them using letters and symbols so that the changes over time of the medical condition can be referred back to the past in an easy-to-see manner. There is. The examination findings are entered using the findings area W1d, which will be described later.

After filling in the medical examination findings, the severity evaluation (step St3) based on the chief complaint and the medical examination findings, the assignment of the diagnosis name (step St4), and the medication treatment instruction (step St6) based on the determination of the treatment policy (step St5). Input the disease name (step St7) and finish the description of the medical record (step St8).
The above is the general flow of medical examinations using electronic medical records. Hereinafter, the configuration and function of the electronic medical record will be described in detail using the displayed screen.

The main window W0 is provided with a plurality of windows (display frames) prepared according to the type of information to be displayed. The upper column in the main window W0 is provided with a bibliographic column displaying the patient's name and various bibliographic items, and the central part in the main window W0 is for inputting medical examination information for entering information at the time of medical examination. A window W1 is provided. The main window W0, which displays the patient's bibliographic items and past medical record information and enables new input of medical record information, selects the patient name from the patient name list (not shown) that displays the patient name in a list. It is generated by doing.

The medical examination information input window W1 is an area for describing the chief complaint, the medical examination findings, the diagnosis, the policy, and the like. The matters recorded in this area are the parts to be examined for medical fees, and when a medical trial occurs, it is the part that can be the subject of a dispute as to whether the medical practice was appropriate. Therefore, the more complete the description content in this area is, the better, but if the description itself takes time, there will be an adverse effect such as the inability to secure sufficient consultation time. The medical examination information input window W1 in the present embodiment is configured in consideration of such circumstances.

Further, in the main window W0, a GUI group display field (function selection windows K and L) in which various GUIs representing operation commands are arranged at a position different from the medical examination information input window W1 and various other windows are provided. Has been done. The function selection window K summarizes the functions related to the recording and creation of medical examination information such as the description of the chief complaint and the findings, and the function selection window L is an order entry for performing examination orders, prescriptions, examination result reference, medical accounting, etc. It summarizes the basic functions of the system and the basic functions of electronic medical records such as printing and termination.
The right column of the medical examination information input window W1 constitutes an instruction column for examination, medication, treatment, etc., and also constitutes an entry column for receipt calculation items and other items.

The configuration and usage of the electronic medical record will be described in detail along the above-mentioned examination flow (steps St1 to St8). The flow shown in FIG. 1 shows the basic flow of the medical examination, but in the actual medical examination, the steps that have passed may be traced back or the steps may be repeated alternately, so they are not necessarily indicated by arrows. It does not have to be in the correct order.
In the step of recording the chief complaint (step St1), the patient is asked about the medical condition, physical condition, temporal changes in the medical condition, etc., and the information is recorded in an electronic medical record. The recording of the chief complaint is started by arranging three types of input windows (W1a, W1b, W1c) having different functions in the medical examination information input window W1.

FIG. 3 shows an enlarged view of the function selection window K. In the function selection window K, various functions for assisting the entry of the medical record are prepared as GUI, and as one example, GUI displayed as "description set" K1 is provided.
When this "description set" K1 is selected, the chief complaint pattern S1a listing the following items is displayed in the chief complaint pattern window W1a as an example, and at the same time, the text window W1b and the image window W1c are displayed as free-form description windows. Will be generated.
Day (before) ~ Fever day (before) ~ Chills Day when chills hurt (before) ~ Headache (pulsatile, tense)
Day (before) ~ Throat pain day (before) ~ Nasal congestion Nasal juice day (before) ~ Cough sputum day (before) ~ Pant (Hu Zero Zei) Suffocating day, afternoon, evening ~ Before bedtime After morning Wake up day (Before) ~ Abdominal pain Epigastric pain Day (Before) ~ Nausea and Vomiting times / day (before) ~ Diarrhea line / day Last defecation (as usual / soft / lively)

When entering the chief complaint heard from the patient, the chief complaint pattern window W1a is selected and instructed with a touch pen (an input device such as a mouse or a keyboard may be used). When the selection is instructed, the editing editor screen D1 displaying the chief complaint pattern S1a shown in FIG. 4 is popped up in the center of the screen, so that information can be input on this screen. The displayed chief complaint pattern S1a is pre-read on the edit editor screen D1, and when recording the chief complaint, information can be input as it is using the touch pen. When the input of information is completed, by selecting "OK" (D2) on the screen, the complaint pattern S1a in which the information is input is arranged in the medical examination information input window W1.
The chief complaint pattern S1a constitutes a chief complaint input format that lists the items and contents necessary for recording the chief complaint, and comprehensively combines the symptoms selected from various complaints of the patient obtained by the past medical examination. It is assumed and provided as a default set.

The above-mentioned chief complaint pattern S1a is made in consideration of simple entry of circles, check marks, numbers, etc. as much as possible. That is, most of the symptoms that are supposed to be recorded as the chief complaint are provided as items in advance so that it is not necessary to enter them in words or sentences. As a result, if the item is marked with a circle, a check mark, or a "+", it means that the item has the symptomatology. On the other hand, if a "-" mark is added, it means that the patient does not have the symptomatism. In addition, for those that require quantitative evaluation and description of symptom type and severity, all you need to do is add a circle, check mark, or arrow to cover all the information necessary for differential diagnosis of the disease and other information that should be described. You can fill in. Body temperature etc. can be described concretely using a stylus. Assuming that the medical examination is performed at a pace of one person every two minutes, it is practically difficult to input the items shown in the complaint pattern S1a by text input using the keyboard or operation using an input device such as a mouse. is there. Therefore, in this embodiment, all entries for the chief complaint pattern S1a are formed on the premise that all entries are made with a touch pen using a tablet or a touch panel.

The editing editor screen D1 has a thumbnail display unit D3 for displaying a list of other editable main complaint patterns to be displayed in the main complaint pattern window W1a. The thumbnail display unit D3 is initially blank, but other main complaint patterns (S1b ...) that can be selected by selecting the lists D5 and D6 displayed in the category area D4 are displayed on the thumbnail display unit D3. It has become like. If you select another chief complaint pattern displayed on the thumbnail display section D3, it can be edited in place of the displayed chief complaint pattern S1a, and by selecting "OK" (D2), the other chief complaint pattern that has been edited is completed. Is placed in the complaint pattern window W1a.
In the other main complaint patterns, it is possible to register a complaint pattern S1a in which the symptoms are entered in advance, and when it is applied as a pattern, the effect of reducing the time for filling in the main complaint is produced. .. The chief complaint pattern in which this symptomatology is entered can be registered by the function provided on the edit editor screen D1.

When the chief complaint pattern S1a arranged in the chief complaint pattern window W1a is selected with the touch pen, the editing editor screen D1 is started again, and editing can be continuously performed. That is, the editing editor screen D1 in which the chief complaint pattern S1a is read is activated, and the editing editor screen D1 in which the editable chief complaint pattern S1a is enlarged and displayed is popped up in the center of the screen. When the editing editor is closed, the chief complaint pattern S1a in which the chief complaint is entered is displayed in the state of the image in which the chief complaint is entered in the medical examination information input window W1.
In the present embodiment, the editing editor screen D1 is configured to pop up at the time of editing, but this is only a part of the function and does not necessarily have to pop up. That is, the chief complaint pattern window W1a itself provided in the medical examination information input window W1 may be configured as an edit editor screen. When a display having a large screen size is used, or when the layout design is such that the area of the medical examination information input window W1 is enlarged, the chief complaint pattern window W1a itself can be used as the editing editor screen.

The chief complaint is the answer to the question asked by the doctor to the patient and the content claimed by the patient regardless of whether or not the question is asked, but when recording, the efficient flow and procedure that each doctor has learned. There is. To reflect this procedure, doctors can create their own complaint patterns as described above. The content of the above-exemplified chief complaint pattern S1a shows an example edited by an experienced doctor.

The editing editor activated at the time of filling in the chief complaint arranges the chief complaint pattern S1a in the lowermost layer of the image layer, and the input of the chief complaint by the doctor or the like is performed on the image layer arranged in the upper layer of the lowermost image layer. For this reason, the characters, figures, etc. written during the examination are written in the upper layer, so that even when adding or deleting, the display content of the complaint pattern S1a itself in the lowest layer may be affected. There is no such thing.
When the complaint is completed, it is finally saved as a single image file that combines all the layers.

The complaint is written using an input device such as a touch panel-equipped display, a pen tablet, a mouse or a keyboard having a detection function by an electrostatic method or a pressure-sensitive method. The main complaint generated by the editing editor is finally stored as one image file, and as described above, it is possible to register it as another main complaint pattern different from the main complaint pattern S1a. The new image file stored as another chief complaint pattern can be displayed selectably on the screen displaying the chief complaint pattern diagram (not shown), and is read as a new chief complaint pattern using this screen. Can be squeezed. As described above, the chief complaint pattern that can be read into the chief complaint pattern window W1a can be added as appropriate.

FIG. 5 shows the chief complaint pattern window W1a, the text window W1b, and the image window W1c arranged on the medical examination information input window W1. The completed chief complaint pattern S1a is displayed on the medical examination information input window W1. Further, in the text window W1b, characters and symbols that can be defined by JIS code, ASCII code, etc. input using the keyboard are input. In the image window W1c, characters written using the touch pen are displayed as image information (image).
When the above-mentioned "description set" K1 is selected, three windows including the above-mentioned chief complaint pattern window W1a, text window W1b, and image window W1c are automatically generated as a set in the vertical direction.

The text window W1b is an area for recording characters and symbols that can be defined by JIS codes, ASCII codes, etc., which are mainly input using a keyboard. The text window W1b can be written or edited by activating the editor function in the window by touching it with a touch pen or pointing it with a mouse.
The image window W1c is an area for recording information input as an image mainly by an input device such as a display equipped with a touch panel, a pen tablet, or a mouse, and constitutes the above-mentioned free description window. In this area, files such as photographs and figures can be read and pasted, and comments can be overlaid and edited.
The image window W1c is touched with a touch pen or pointed with a mouse to start an editing editor and a pop-up window is displayed in the center of the screen (not shown). Since this edit window records the input information as image data, it is possible to freely write without restrictions.

Writing or correction to each window of the chief complaint pattern window W1a, the text window W1b, and the image window W1c can be accessed and added or corrected at any time as long as the medical examination information input window W1 is not closed.
Since it is completely unpredictable in what order and content the complaints that the patient will complain at the time of examination, immediately select the window to record according to the content of the patient's speech, and input the complaint without interruption while switching windows. You can do it. By selecting the "description set" K1, three windows (W1a, W1b, W1c) having different functions were provided, as described above, the patient's complaints alleged at various timings and contents were immediately and without interruption. This is so that it can be recorded in.

To close each window (W1a, W1b, W1c) (to finish addition and editing), touch the part other than the window with the touch pen or click with the mouse to close it. Further, by touching any window with a touch pen or clicking with a mouse, an editor screen corresponding to each window (W1a, W1b, W1c) is instantly activated, and addition, correction, etc. are possible.
As shown in FIG. 5, in the medical examination information input window W1, the description contents made for each window (W1a, W1b, W1c) are arranged in a list.
Each window (W1a, W1b, W1c) once written on the medical examination information input window W1 can be deleted in window units by a menu operation displayed by right-clicking with the mouse.

The text window W1b is provided as a blank with a height for displaying characters for three lines in the initial state in which the text window W1b is arranged. Visually, a blank is provided at the lower end of the complaint pattern window W1a, which has the effect of visually clarifying the arrangement of the complaint pattern window W1a.
The task of inputting information into the medical record while conducting a medical examination is a task that involves various thoughts. For example, what kind of medication should be given at the same time as the diagnosis, what kind of treatment policy should be taken, how to connect to the next examination, how to end one session of interaction with the patient. It is a task to think about various things at the same time while conducting a medical examination and inputting medical records, such as how to speak in easy-to-understand words what must be conveyed to the patient. In order to process such thoughts and tasks in a short time, the task of inputting the medical record and the task of browsing the already entered information do not interfere with the thinking, and in particular, look for the input contents that have already been entered and should be browsed. It is desirable to eliminate as much as possible the factors that must be collected. When sensations that interfere with thinking are evoked from within the visual cortex of the brain, it seems that thinking must be focused not only when it requires more energy than necessary and the examination must be completed in a short time. In any case, thinking is hindered.

In the electronic medical record according to the present embodiment, the area where information regarding the chief complaint needs to be input is arranged in the upper half of the central vertical area of the entire wide screen. That is, the medical examination information input window W1 is arranged in the vertical region in the center of the main window W0, and the chief complaint pattern window W1a is provided therein. In the case of a 24-inch display that displays the main window W0 having the aspect ratio shown in FIG. 2, the width of the medical examination information input window W1 is formed to be about 1/5 of the total width of the main window W0. There is. The actual size is a region with a width of about 8 to 10 cm. The height of the area for describing the main complaint, which is composed of the main complaint pattern window W1a, the text window W1b, and the image window W1c, is about 12 to 15 cm in the initial state. As long as the area has this shape and area, it is possible to guarantee the size of figures and characters that does not impair visibility. The reason why the occupied space of each window (W1a, W1b, W1c) is intentionally narrowed down to the above size is that the information to be contained in the field of view is not diffused by arranging it only in a relatively narrow area. In the thinking process of narrowing down the diagnosis and treatment policy method while browsing and confirming the information of the chief complaint extracted from the patient, in synchronization with focusing the eyes on the narrow area, deeply without spreading the thought during the examination. Because you can concentrate. At the same time, the wording prepared as a fixed phrase is composed of words excluding "desu" and "masu", which has the effect of instantly grasping information.
Further, by arranging each window (W1a, W1b, W1c) in a rectangular area having the above-mentioned dimensions, the distance for moving the viewpoint to each input field including the complaint pattern input window W1a is small, and each input is intuitive. You can access the fields.

Further, by providing a text window W1b that forms a blank line in the initial state in the lower column of the complaint pattern window W1a, the arrangement of the complaint pattern window W1a has an effect of making the arrangement of the complaint pattern window W1a stand out and visually close up. This visual action reduces the work in the brain of searching for the chief complaint pattern window W1a, and thus has the effect of not interrupting various thoughts and input work associated with the diagnosis.

The "description set" K1 displayed on the GUI corresponds to the start button for inputting the electronic medical record. "Description set" K1 is the easiest for doctors who are prepared to listen to the story face-to-face with the patient and describe the content on the medical record at the same time when opening the electronic medical record. And it is located in a position that is easy to approach with the input device.
Specifically, the "described set" K1 is arranged in the upper left corner of the function selection window K in which a plurality of GUIs are arranged in a matrix. The function selection window K has a plurality of selectable tags described as "basic", "description", "P / α", "inspection", "disease drug", "book, etc." in the upper column, and is selected. There are pages with different GUIs listed for each tag. The tag is selected according to various operations performed on the electronic medical record, and the required GUI is selected from the list notation displayed by the tag selection and executed.

The purpose of the electronic medical record of the present embodiment is to fill in the medical examination contents efficiently and overwhelmingly quickly. As mentioned above, one means to achieve that purpose is to arrange three windows with different input functions at the same time when describing the complaint so that input can be started from any window and the input information can be corrected at any time. That's what I did.
In addition, as one of the means to achieve the above-mentioned purpose, the GUI for arranging the three windows used when describing the chief complaint at the same time is arranged in the upper left corner of the function selection window K to discover the GUI. It's easy. The doctor has a face-to-face conversation with the patient, and when he / she hears the information that is the main complaint, he / she immediately starts inputting. At that time, when the line of sight is transferred from the patient to the display, the GUI is arranged so that it can be found immediately.
Further, although the function selection window K has a plurality of pages selected by the tag, the GUI in which the description set of the chief complaint is read and arranged is arranged at the same position in other a plurality of frequently used pages. ing. That is, no matter which tag is selected (on any page), the GUI for reading the description set is provided at the same position, so that the operation of operating the tag to display the GUI can be omitted. It has become.

The text window W1b and the image window W1c are automatically deleted from the medical examination information input window W1 when a series of input processes are completed without any entries. The chief complaint pattern window W1a is arranged in the medical examination information input window W1 as one image file regardless of whether or not it is filled in, but when it is unnecessary, it can be deleted individually as described above. When the patient complains of a new chief complaint after a certain writing is completed, the set of each window is newly called by using the "statement set" K1 and the necessary information is written. In this case, a new set of each window (W1a, W1b, W1c) is continuously generated without affecting the already written information of the W1 window.

As described above, the content of the chief complaint pattern S1a corresponding to the "statement set" K1 can be edited independently so as to be easy to use according to the medical examination procedure and flow of the doctor who uses it, and the entry of the chief complaint is It is possible to input quickly as if writing on a paper chart. With such a configuration, the electronic medical record according to the present embodiment can quickly and quickly fill in the symptoms based on the chief complaint and time-based or quantitative information at the level of seconds, and can display and record the information. It has become.

In the above-described example, three windows, a main complaint pattern window W1a, a text window W1b, and an image window W1c, are generated in the medical examination information input window W1 by the selection instruction of the “description set” K1. However, as another embodiment, for example, when the "description set" K1 displayed in the function selection window K is selected, the editing editor screen D1 in which the chief complaint pattern S1a is read in advance is displayed in a pop-up in the center of the screen. It may be configured as follows.
In this case, the chief complaint pattern S1a having the content shown in FIG. 4 is loaded in advance on the edit editor screen D1 as a default, and when recording the chief complaint, the information is input as it is using the touch pen. be able to. When the input of information is completed, by selecting "OK" (D2) on the screen, the complaint pattern S1a in which the information is input is arranged in the medical examination information input window W1. At this time, at the same time, a text window W1b and an image window W1c are generated as free-form description windows. That is, three input windows (W1a, W1b, W1c) for inputting the chief complaint are generated.
When "OK" (D2) is selected without entering anything on the above editing editor screen D1, the editor function is terminated and the main complaint pattern window W1a displaying the blank main complaint pattern S1a is displayed in the text window W1b. And the image window W1c are arranged in the medical examination information input window W1. The chief complaint pattern S1a constitutes a chief complaint input format that lists the items and contents necessary for recording the chief complaint, and comprehensively combines the symptoms selected from various complaints of the patient obtained by the past medical examination. It is assumed and provided as a default set.
The editing editor screen D1 has a thumbnail display unit D3 for displaying a list of other editable main complaint patterns to be displayed in the main complaint pattern window W1a. When the edit editor screen D1 is started using the "description set" K1, the thumbnail display unit D3 is blank, but it can be selected by selecting the lists D5 and D6 displayed in the category area D4. Other main complaint patterns (S1b ...) Are displayed on the thumbnail display unit D3. If you select another chief complaint pattern displayed on the thumbnail display section D3, it can be edited in place of the main complaint pattern S1a displayed as the initial setting, and editing is completed by selecting "OK" (D2). The main complaint pattern of is placed in the main complaint pattern window W1a. In this way, the "description set" K1 can input the main complaint using an arbitrary chief complaint pattern S1a as an initial setting, and if it is desired to use another chief complaint pattern, another prepared in advance. The chief complaint pattern can be selected and used as appropriate.
In the other main complaint patterns, it is possible to register a complaint pattern S1a in which the symptoms are entered in advance, and when it is applied as a pattern, the effect of reducing the time for filling in the main complaint is produced. .. The chief complaint pattern in which this symptomatology is entered can be registered by the function provided on the edit editor screen D1.

Next, Step St2 for entering the medical examination findings of the doctor will be described with reference to FIGS. 6 and 7. When entering the doctor's medical examination findings, the doctor assumes the diagnosis result through the chief complaint and records the necessary findings.
To enter the medical examination findings, select "Figures" K2 arranged as a GUI in the function selection window K by an input means such as a mouse or a touch pen. The "Figures" K2 is arranged near the center of the function selection window K. As described above, the function selection window K has a plurality of pages selected by the tag, but the "Figures" K2 is arranged at the same position on the other frequently used pages. That is, no matter which tag (page) is selected, the "Figures" K2 is always in the same position (near the center), so the operation of operating the tag to display the "Figures" K2 can be omitted. It has become like.
When "Figures" K2 is selected, a finding pattern diagram list W2 displaying a list of a plurality of finding pattern diagrams constituting the finding input format is displayed on the left side of the main window W0. The record of the findings can be input from the middle of step St3 and thereafter. It is normal and assumed that each step goes back and forth in the actual flow of medical record description.

FIG. 7 shows an example of a plurality of finding pattern diagrams displayed as a finding pattern diagram list W2. In addition to the default findings pattern diagram list W2, the default findings pattern diagram can be used to add or modify the description, or the doctor can use the editor function for editing to create a completely original one. You can register your own creations and edits. Originally created or edited ones are published in the finding pattern diagram list W2 as a new readable finding pattern diagram.
In the finding pattern diagram list W2, as an example, a thumbnail image showing an illustration showing a body part and a wording expressing a group of findings to be checked in the part shown in the illustration as characters is shown in the finding pattern diagram (S2a, S2b). , S2c ... S2x) can be selected and displayed in a list.
The finding pattern diagram includes a finding pattern diagram S2x in which information about the presence or absence of findings is not entered, and a finding pattern as a finding-described format that constitutes a written finding in which findings that are repeatedly observed as actual medical examination findings are entered in advance. There are figures (S2a, S2b, S2c ...).

Each finding pattern diagram displayed as a thumbnail in the finding pattern diagram list W2 is composed of three elements. Taking the finding pattern diagram for the common cold sli.flare as an example, the first is the check box g1, the second is the finding name g2 that outlines the findings such as "cold sli.flare", and the third is the finding name g2. It is an image part g3 which constitutes the main body of a finding pattern figure. There are two ways to display the findings pattern diagram configured in this way for the medical examination information input window W1.
The first method is a method in which the check box g1 or the finding name g2 is selected and the GUI "registration" g4 in the finding pattern diagram list W2 is selected with a touch pen, a mouse, or the like. In this case, the finding pattern diagram is arranged in the medical examination information input window W1 as it is without starting the editing editor. After arranging it once, if the finding pattern diagram in the medical examination information input window W1 is selected with a touch pen, a mouse, or the like, the editing editor is activated and information can be input.

The second method is to select the image unit g3 with a touch pen, a mouse, or the like. When this operation is performed, an editing editor screen similar to that shown in FIG. 9 or 10 is popped out and information is displayed. You will be able to input. When the input is completed and the GUI "OK" is operated, the edit editor screen is closed, and the finding pattern diagram is displayed as a thumbnail image in the finding pattern diagram list W2 together with the input information. After that, when "registration" g4 is selected with a touch pen, a mouse, or the like, the finding pattern diagram in which the information is input is displayed in the finding area W1d in the medical examination information input window W1.
When the finding area W1d is generated, the chief complaint pattern window W1a, the text window W1b, and the image window W1c that have already been displayed in the medical examination information input window W1 move downward.

When adding or modifying the finding pattern diagram displayed in the finding area W1d, select the finding pattern diagram displayed in the finding area W1d and the edit editor screen will be popped out again. You can add or modify using the edit editor screen in the same procedure as above.
The editing editor does not necessarily have to display the editing window in a pop-up in the center of the screen, and may be configured such that the finding area W1d is used as an editing screen to enter, add, or correct findings.

The finding pattern diagram S2a selected from the finding pattern diagram list W2 was created by the doctor himself as described above, and shows the body part represented as a sketch and a plurality of finding items to be obtained through examination at each part. Listed in advance. The presence / absence of each symptom and the positive / negative are indicated by +/-. In this example, only "-" indicating a negative is posted in advance corresponding to the symptom, and in the case of positive, a vertical line "|" is written so that + can be displayed. In this way, in order to minimize the time required for inputting information, the +/- symbol display is adopted.

Although there are differences in the fields of medical care and patient groups in charge, there is a certain tendency for all doctors regarding the disease group, symptom group, and finding group that they frequently handle. Most of the actual consultation hours are spent on repeated examinations of the patient group and medical records of the symptomatology group and the findings group in line with such a tendency.
Symptoms and findings that are naturally obtained from such patient groups present common observations, and doctors can, with some experience, create in advance patterns of combinations of frequent findings. Based on this point of view, a finding pattern in which the combination of presence / absence for each of a plurality of finding groups is described in advance is created, and the finding entry time is set so that it can be selected from the finding pattern diagram list W2. It can be done in a short time.

9 (a) to 9 (e) are explanatory views of an editor mode in which the finding pattern diagram can be edited. The editor mode has an edit screen E1. The edit screen E1 is a screen for creating a finding pattern diagram for reading into the medical examination information input window W1 by reading an image file, inserting a picture, drawing a picture, and arranging input characters. The created finding pattern diagram is published in the finding pattern diagram list W2.
The category column E2 is an area displaying a list of folders of systematic categories classified by parts and organs of the human body, and displays a folder for registering or reading the created finding pattern diagram according to the category. It is a column.

The finding pattern diagram list column E3 is an area for displaying a thumbnail list of the finding pattern diagrams stored in the folder selected in the category column E2. The figure selected in the finding pattern figure list column E3 is displayed on the edit screen E1 and can be edited.
In FIG. 9A, one of the categories, "frequently appearing" E2a, is selected in the category column E2, and the "basic entry" displayed as a thumbnail from the finding pattern diagram list column E3 displayed by selecting the "frequently appearing" E2a. The screen "E3a" is selected, and the selected "basic entry screen" E3a is expanded and displayed on the edit screen E1.

The finding pattern diagram E4a expanded and displayed on the editing screen E1 can be stored in a folder set in the category column E2 under the name of "for one-touch registration" E2b, for example. The finding pattern diagrams E4b, E4c, E4d, and E4e shown in FIGS. 9 (b) to 9 (e) represent an example of the finding pattern diagram edited on the editing screen E1. These findings pattern diagrams can be created and stored in advance by a doctor based on his / her own experience, in which a combination of the presence or absence of findings, which is often seen as a medical examination finding, is patterned. By creating and storing in advance in this way, when the examination findings are entered in a short examination time of about 2 minutes, the entry work can be greatly shortened.

To briefly show another example, FIG. 10 (a) is a finding pattern diagram E5a relating to the “genital anal diagram” expanded and displayed on the editing screen E1, and FIG. 10 (b) is a “preliminary examination finding”. The findings pattern diagram E5b relating to the "genital anal diagram" is shown. Further, FIG. 10 (c) is a finding pattern diagram E6a relating to the “eye-ear findings” expanded and displayed on the editing screen E1, and FIG. 10 (b) relates to the “eye-ear findings” in which the examination findings are pre-filled. The finding pattern diagram E6b is shown.

In the flow of medical examination using an electronic medical record, after completing the entry of medical examination findings (step St2), input of severity evaluation (step St3), input of diagnosis name (step St4), based on the chief complaint and medical examination findings, The treatment policy is input (step St5), the medication treatment instruction is input (step St6), and the disease name is input (step St7), and the series of electronic medical record input is completed (step St8).
After describing the medical examination findings using the findings pattern diagram (S2a, S2b, S2c ... S2x), select "Diagnosis &Policy" K3 displayed in the function selection window K, and enter the severity evaluation (step St3). Severity evaluation input field (Assessment field) W1e to perform the diagnosis name input field (Tentative Dx field) W1f to perform the diagnosis name input (step St4), treatment policy input field to perform the treatment policy input (step St5) (Plan column) W1g, other "Note" column W1h and "Notes column" W1i are generated.

The severity evaluation input field W1e is a combo box in which "fixed phrases / phrases" are listed in a pull-down format when the field is selected, and is selected from the "fixed phrases / phrases" displayed in the list. Things are automatically entered. It is also possible to input text using the keyboard without selecting the ones displayed in the list. In the illustrated example, the case where the wording "poor vitality / poor general condition" is automatically input is shown.
Further, the diagnosis name input field W1f, the treatment policy input field W1g, the Note field W1h, and the caution field W1i are displayed in the "fixed phrase / phrase" list M (see FIG. 8) in which the fixed phrase / phrase to be input can be selected. It is automatically entered by selecting the one posted. Of course, each of these fields is configured so that input using the keyboard is possible instead of automatic input.

The entry of Tentative Dx (W1f) for entering the diagnosis name is in "Plan:" (W1g), which forms part of the treatment policy entry, in "Diagnosis name → Treatment policy" in the "Fixed phrase / phrase" list M. The input area is "Situation evaluation->policy" in the "Fixed phrase / phrase" list M, and "Note:" (W1h), which forms part of the treatment policy entry, is "Specific" in the "Fixed phrase / phrase" list M. For "Notes:" (W1i), which forms part of the treatment policy entry in "Target / Inhalation Instruction", select the category displayed as "Assessment &Plan" in the "Standard sentences / phrases" list M. With, you can select and enter each detailed input content.
After inputting information for each of the above areas, writing to the W1 area is completed by clicking or touching any part of the main window W0.

After deciding the treatment policy as described above, the medication treatment instruction (step St6) and the disease name input (step St7) are performed based on the treatment policy, and the description of the medical record is completed (step St8). The above is the general flow of medical examinations using electronic medical records.
As described above, the matters described in the embodiment of the invention can be appropriately combined within the range not deviating from the gist of the present invention described in the claims, and are described including this combination. ..

The present invention can be used for medical examinations using electronic medical records.

W0 Main window W1 Medical examination information input window W1a Chief complaint pattern window W1b Text window W1c Image window W1d Finding area W1e Severity evaluation input field W1f Diagnosis name input field W1g Treatment policy input field W1h Note field W1i Precautions field W2 Finding pattern diagram list K, L Function selection window S1a, S1b Chief complaint pattern S2a, S2b, S2c Finding pattern diagram S2x Finding pattern diagram with no information about the presence or absence of findings K1 command (described set)
K2 "Figures"
K3 "Diagnosis &Policy"
D1 Edit editor screen D2 "OK"
D3 Thumbnail display section D4 Category area D5, D6 List g1 Check box g2 Finding name g3 Image section g4 "Registration"
M "Fixed phrase / phrase" list E1 Edit screen E2 Category column E2a "Frequent"
E2b "For one-touch registration"
E3 Finding pattern diagram list column E3a "Basic entry screen"
E4a, E4b, E4c, E4d, E4e Finding pattern diagram E5a, E5b Finding pattern diagram E6a, E6b Finding pattern diagram

Claims (8)

An arithmetic processing means having a CPU for executing a program, a display for displaying an image by executing the program, an electronic medical record having a keyboard and a touch pen for inputting information and operation instructions.
A main complaint area for displaying the main complaint of the patient obtained by the interview arranged on the medical examination information input window displayed on the display, a finding area for displaying the medical examination findings obtained by the medical examination, and the main complaint area are generated. It has a function selection window in which a GUI with a function to be set and a GUI with a function to generate a finding area are arranged.
The complaint area includes a complaint pattern window that displays the complaints recorded in a standard format or a standard format in which information about the complaint is represented by an image, a text window that allows text input using a keyboard, and a text window that allows text input using a keyboard. It has an image window that is displayed as editable image information by writing and drawing with a touch pen.
An electronic medical record characterized in that a chief complaint pattern window, a text window, and an image window are simultaneously generated in accordance with an operation of a GUI in which a function for generating a chief complaint area is set. It has an edit editor function for editing the complaints recorded using the standard format or the standard format displayed in the complaint pattern window.
The claim is characterized in that the editing editor function is configured to be activated by selecting and instructing a standard format or a main complaint recorded using the standard format displayed in the main complaint area. 1 The electronic medical record described. It has an edit editor function that records the chief complaint using the standard format displayed in the chief complaint pattern window that is activated by selecting the GUI that sets the function to generate the chief complaint area, and at the end of the edit editor function. The electronic chart according to claim 1, wherein the chief complaint pattern window, the text window, and the image window are generated accordingly. It has an editing editor that is activated by selecting a GUI that has a function to generate the finding area, and the editing screen by the editing editor function is selected from a plurality of pre-registered finding input formats formed as image information. It is composed of one finding input format and an input layer displayed on top of the selected finding input format, and an image in which the finding input format and the layer are combined is displayed on the medical examination information input window. The electronic chart according to any one of claims 1 to 3, wherein the electronic chart is configured. The medical examination information input window is arranged substantially in the center of the display screen constituting the electronic medical record, and is also arranged.
The invention according to any one of claims 1 to 4, wherein the chief complaint pattern window, the text window, and the image window constituting the chief complaint area are arranged downward in the order in the medical examination information input window. Electronic medical record. The text window and the image window are any one of claims 1 to 5, wherein the text window and the image window are configured to be automatically deleted from the medical examination information input window when the information is not input. Described electronic medical record. The finding input format is composed of an image file consisting of graphic information representing a part of the human body as an illustration and text information listing physical findings that may occur in the part of the human body represented as the illustration. The electronic medical record according to claim 4, wherein the electronic medical record is characterized by the above. The editor function can generate a plurality of pre-described findings-described formats in which the findings expected at the time of medical examination are described in the above-mentioned findings input format in advance.
The electronic medical record according to claim 4, wherein the created finding-described format is displayed in a selectable list together with other finding input formats, and is configured to be read in the finding area.

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