JP6000507B2 - Medical information registration device - Google Patents

Description

  The present invention relates to an apparatus for registering patient medical information in a medical institution, and more particularly to an apparatus for simply inputting an uncoded disease name.

  An apparatus for registering patient medical information in a medical institution registers information on the name of a disease that is a target of the medical practice in addition to medical practice such as treatment and medication. Since such medical information is given a master code determined by a public institution for each treatment, drug, and disease name for calculating medical fees, the medical information is registered together with the master code. Then, when the medical fee is requested, the master code is used for the request. Processing data for medical fees in this way by an electronic computer and issuing a medical fee bill (so-called receipt) is called a receipt computer processing, and a master code used at that time is also called a receptacle computer code. In recent years, online billing has become widespread, and it is strongly recommended that the disease name is not written in character strings but the receipt computer code is used. However, the receipt computer code has a large number of digits, so it is not suitable for input as it is. Conventionally, in order to simplify the input, an easy-to-remember code consisting of several digits and numbers unique to each medical practice. Is assigned and entered using that code. That is, in such a device, a code of several digits is attached to each medical treatment item such as medical examination fee, medical treatment fee, medical examination item, examination, medicine, and disease name. It is registered in the database, and the operator inputs it using the code while referring to the medical record and prescription. This code is called a medical code or a user code. Moreover, since this database is created for each medical institution that is a user, it is called a user code database. The contents to be registered in the database include: the medical code used for input, the official name and reading of the medical practice, reading kana or furigana, the point drug price used as the basis for calculating medical expenses, in the case of drugs, the unit of measurement, classification, and the receipt computer code Etc.

  The applicant of the present application has proposed a code input device that automatically replaces a disease name written in a medical record by a doctor with a character string as it is (see Patent Document 1).

JP 2005-250657 A

  The name of the disease described by the doctor in the medical record may be encoded, that is, the name of the disease registered in the user code database, that is, the name of a standard disease, but the name of a disease that is commonly used is often described. . For example, a case where “ringworm” should be described as “athlete's foot”. If there is a clear correspondence such as ringworm and athlete's foot, it can be handled by entering the code for ringworm that is the correct (standard) disease name at the operator's discretion, but if there is a similar disease name, the operator It is difficult to leave it to the judgment. This is because only standard disease names with master codes are registered in the user code database. In addition, there are cases where doctors themselves input disease names, such as an electronic medical record device, and there has been a need for a device that replaces conventional disease names entered in character strings (text) with standard disease names that are efficiently encoded. .

The present invention is a medical information registration apparatus for registering data of a patient's disease name as patient's medical information, and a master registered with a master code attached to data related to a medical fee claim for each name of a medical practice including a disease name A code database, a user code database in which data related to a master code is registered with a user code specified by the user, a disease name and a qualifier are registered, a standard disease name of a disease name with a master code, and an idiopathic disease name The standard disease name database registered in association with each other, the patient disease name database in which the history of the disease name is recorded, the input means for inputting the name character string of the disease name, and the input means if the disease name is an uncoded disease name If the disease name in the user code database is searched using the specified name string, and the search is successful, the matching disease name data Disease name and the master code registered in the patient disease name database as patient disease name data, if the search is not hit, retrieves the disease name master code database under the name string, a disease name and the master code is data matched Disease A method for registering in the user code database, registering the disease name and master code as patient disease name data in the patient disease name database, and replacing an uncoded disease name with a coded disease name, where the uncoded disease name includes a modifier If, out of the input means including name string modifier that has been received, and the name character string of the standard name of a disease that only the string of conventional disease name was replaced by the standard name of the disease, was attached to the name character string of the standard name of the disease master and means for registering a code location-out place name of disease dictionary, prior to searching for user code database, input hand Is first searched for Disease dictionary replaced with the name string accepted, the disease name obtained by searching the user code database on the master code attached to the name string of the acquired standard disease name, a master code, the patient The above-mentioned problem is solved by registering in the patient disease name database as disease name data.

  According to the medical information registration device of the present invention, it is possible to automatically replace an uncoded disease name input as a character string with a conventional disease name or the like with a standard disease name that has been coded.

It is a block diagram which shows the structure of the medical treatment information registration apparatus of embodiment. It is a figure which shows the record structure of a user code database. It is a figure which shows the record structure of a standard disease name database. It is a display example of a disease name input screen. It is a flowchart which shows a process sequence.

  FIG. 1 shows the configuration of a medical information registration apparatus 100 according to an embodiment of the present invention. Reference numeral 1 denotes a control means configured by an MPU, which controls the operation of the entire apparatus, 2 an input means such as a keyboard or a mouse device, 3 a display means such as a CRT, and 4 a storage means constituted by a hard disk device or the like. This storage means stores various databases described below.

  Reference numeral 10 denotes a user code database in which codes of medical treatment items that may be used in the medical institution are registered in advance. The disease name is also registered. In addition, a prefix indicating a part of the right hand or a hand in case of a right hand fracture, and a suffix such as “no doubt” in case of suspected influenza are registered.

  A record structure of the database 10 is shown in FIG. It consists of a user code 11 used by an operator, a name 12, a reading 13, a score drug price 14, a category 15, a unit 16, a master code (ie, a computer code) 17 and additional information 18. ing. Since the database determines the medical practice, the medicine, and the disease name to be registered according to the circumstances of the medical institution that is the user, the contents differ for each user. Also, the user code often uses readings, but since the user code is determined freely, it is usually different for each user.

  Reference numeral 20 denotes a master code database, which is registered with a master code attached to data of all medical treatment items (including treatments, disease names, and medicines) to be subjected to the receipt computer processing. This is a database provided by the manufacturer, and is a manufacturer master that is commonly used by all users. Data related to individual master codes, such as necessary medical practice and disease names, is extracted from the master database, and a user code is attached and registered in the user code database.

  Reference numeral 30 denotes a standard disease name database in which standard injury and disease names for receipt computer processing and disease name exchange are registered. The database includes an index table, a disease name table, and a modifier table. As shown in FIG. 3, the disease name table includes a disease name notation 31 that is a Kanji notation of a standard disease name, a disease name notation 32 that is a kana notation, and a standard name. An abbreviated name 33 in which a disease name is omitted, a master code 34, and ICD-10 information 35 are registered. In the index table, link information 37 and synonym classification 38 to the disease name table and the modifier table are registered for each index term 36. Here, the index term 36 includes not only a standard disease name but also a conventional disease name, and the synonym classification 38 registers a distinction as to whether the index disease name is a standard disease name, a synonym or a synonym. . Therefore, in the case of an idiopathic disease name, the synonym section 38 is registered as a synonym or synonym section. The link information 37 is an index indicating a term on the disease name table corresponding to the index term 36, that is, a standard disease name.

  A medical information database 40 records medical data for each patient. Basically, data such as treatments and medications received by the patient is recorded in units of treatment days.

  Reference numeral 50 denotes a patient disease name database in which a history of disease names of patients affected is recorded. The disease name data includes a start date, an outcome date, outcome information, a disease name name (character string), and a master code thereof.

  Reference numeral 60 denotes a replacement dictionary database, which records the correspondence between a common disease name and a standard disease name when the common disease name entered as a character string is replaced with a standard disease name and registered in the patient disease name database. A character string of a common disease name, a character string of a standard disease name (the disease name notation 31), and a master code thereof are recorded. Since the disease name is often combined with a prefix or suffix, the code recorded here is basically a combination of a plurality of codes.

  FIG. 4 is a display example of the disease name input screen 70. The upper part is a patient information area in which information related to the medical treatment date and the patient is displayed, and the lower part is a disease name display area for displaying the current disease name of the patient. The lower part is an input area for inputting and editing a disease name, and includes a field 72 for inputting a disease name code and a field 71 for directly inputting a disease name as a character string (text). Each of the disease name data has information on a start date, an outcome, and an outcome date, and a field for inputting them is provided. The start date is the date when the doctor examined and assigned the name of the disease, the outcome is the result of the disease progressing, for example, healing or death, and the outcome date is the date on which the outcome was determined. Then, the disease name input in the input area is displayed in the disease name display area. The control device displays the disease names with sequential numbers in the order of input, and displays the asterisk “*” next to the serial numbers for the disease names input as character strings. This is called an uncoded disease name, and the disease name is registered as a character string in the new remuneration request data.

  When the doctor or operator has entered the necessary disease name, the end of the disease name input is instructed. In this embodiment, since the keyboard is provided with an “end key”, it is pressed. In response to this, the control device registers the disease name data input and displayed in the disease name display area in the patient disease name database. At this time, if there is a disease name with an asterisk “*”, that is, an uncoded disease name, a process of replacing it with an encoded disease name, that is, a disease name registered in the user code database is executed (step S13; Yes). In that case, a message indicating that the uncoded disease name is being replaced with the coded disease name is displayed in the disease name input screen.

  Therefore, first, the replacement dictionary database is searched with the uncoded disease name (S14). If there is a track record of replacing the uncoded disease name with the previously coded disease name, the master code of the corresponding standard disease name can be obtained immediately, so the user code database is searched with the master code, the disease name data is read, Register in the patient disease name database (S23).

  On the other hand, if no search hit is found in the replacement dictionary database, that is, if there is no match and the search fails, then the user code database is searched with the uncoded disease name (S16). If there is a search hit, a disease name code of the same name 22 as the uncoded disease name exists in the user code database, and the disease name code is registered in the patient disease name database (S24).

  On the other hand, if no search hit is found, the master code database is searched with the uncoded disease name (S18). If there is a search hit, the disease name code of the same name 22 as the uncoded disease name exists in the master code database, so the disease name code is automatically registered in the user code database (S25), and the code is used. Register in the patient disease name database. This is a reduction in registration work in the user code database, which occurs when it exists in the master code database but is not registered in the user code database for the medical institution, and the same code when the same disease name is entered. It is for using.

  On the other hand, if the search hit does not occur, the index table of the standard disease name database is searched with the uncoded disease name (S20). The index table contains not only standard disease names but also synonyms and synonyms of common disease names. If a search hit occurs, the disease name table of the standard disease name database is referred to by the link information, and the master code is obtained therefrom. Then, using this master code, the user code database and then the master code database are searched again (S22). If a search hit occurs in the user code database, the disease name code is registered in the patient disease name database as described above. If no search hit is found, the master code database is searched. Since all the master codes are registered in the master code database, it always hits. Therefore, as described above, the disease name code is registered in the user code database and registered in the patient disease name database.

  Then, when the uncoded disease name is replaced with the coded disease name, the control device registers the corresponding relationship in the replacement dictionary database. Specifically, the character string of the uncoded disease name as the heading, the character string of the replaced standard disease name, and the master code thereof are registered. As a result, when the uncoded disease name is input next, the replacement dictionary database is first searched, so that the standard disease name to be replaced can be obtained immediately.

DESCRIPTION OF SYMBOLS 100 Medical information registration apparatus 1 Control means 2 Input means 5 Display means 4 Storage means 10 User code database 20 Master code database 30 Standard disease name database 40 Medical information database 50 Patient disease name database 60 Replacement dictionary database

Claims (2)

A medical information registration device for registering data of a patient's disease name as patient medical information,
A master code database registered with a master code attached to data related to a medical fee claim for each name of a medical practice including a disease name;
A user code database in which data related to the master code is registered with a user-specified user code, and the disease name and modifier are registered;
A standard disease name database in which the standard disease name of the disease name to which the master code is attached and the conventional disease name are registered in association with each other;
A patient disease name database in which a history of the disease names is recorded;
An input means for inputting a disease name string;
When the disease name is an uncoded disease name, the disease name in the user code database is searched with the name character string input by the input means, and when the search is hit, the disease name and the master that are data of the matched disease name If the search is not hit when the code is registered in the patient disease name database as a patient disease name data, the disease name in the master code database is searched with the name character string, and the disease name and the disease name data that match Means for registering a master code in the user code database, registering the disease name and the master code in the patient disease name database as patient disease name data;
When replacing the uncoded disease name with a coded disease name, and the uncoded disease name includes the modifier, the name of the idiopathic disease name among the name strings including the modifier received by the input means A name character string of the standard disease name in which only the character string is replaced with the standard disease name, and a means for registering the master code attached to the name character string of the standard disease name in a replacement disease name dictionary,
Prior to the search of the user code database, the replacement disease name dictionary is first searched with the name character string received by the input means, and the user code database with the master code attached to the acquired name character string of the standard disease name. A medical information registration apparatus for registering a disease name obtained by searching for and a master code in the patient disease name database as patient disease name data. Said means for registering, the search for disease name of the master code database under the name string, before Symbol If the search does not hit, retrieves the standard disease name database with the entered name character string by said input means, The master code of the matched standard disease name or common disease name is acquired, the user code database is searched with the master code, and the disease name and the master code are registered in the patient disease name database. Medical information registration device.