JP6933436B2 - Medical document creation system and medical document creation program - Google Patents

Description

Embodiments of the present invention relate to a medical document creation system and a medical document creation program.

The medical document creation system or the medical document creation system can support the diagnosis of the patient and the medical office work by the computer. This type of system is used regardless of the size of medical bases such as general hospitals, university hospitals, and regional clinics, and may be introduced in cooperation with electronic medical record systems.

Medical documents range from various prescriptions, referral letters, medical information provision forms, and medical certificates. Therefore, a standard document format (template) is prepared in advance, and pre-registered data (patient basic information (patient number, patient name, date of birth, gender, etc.), disease name, test result, vital, etc.) is used as a template. It has been conventionally inserted into. The technology known as "mail merge" in commercially available application software (word processing software / form software, etc.) is a technology similar to this. This type of technology can be used to increase the efficiency of creating medical documents.

Japanese Unexamined Patent Publication No. 2014-056570 Japanese Unexamined Patent Publication No. 2000-200156 Japanese Unexamined Patent Publication No. 2004-145571

In the template (order input screen) in which data for each patient is inserted, patient-specific data is quoted along with the patient's name and age. The cited data can also be modified or edited after the fact.

However, there is no known technology that allows the order input screen itself to be processed or changed. There are various circumstances surrounding the medical environment such as clinical departments and regional characteristics, and there are many needs to change (modify, customize) the input items and their layouts on the order input screen according to such unique circumstances. In a relatively large hospital, it is possible for a service person to visit and modify the software each time, but it is difficult for a small clinic to handle such a situation. There is a demand for a medical document creation system that makes it easy to customize the order input screen, and this need is particularly high in clinics where it is difficult to rely on engineers who are familiar with software interface modifications.

The purpose is to provide a medical document creation system and a medical document creation program that enable the order input screen to be easily customized.

The medical document creation system of the embodiment includes a display unit, a database that holds information unique to each patient, a document creation means, and an order input screen editing means. The document creation means creates a medical document that reflects the contents input on the order input screen including a plurality of items and the information acquired from the database. The order input screen editing means customizes the order input screen by arranging an input control selected from a plurality of input controls prepared in advance on the initial screen.

It is a functional block diagram which shows an example of the medical document creation system which concerns on embodiment. FIG. 2 is a flowchart showing a processing procedure for inputting a general-purpose document order in the medical document creation system 1 of FIG. FIG. 3 is a diagram showing an example of an order input screen. FIG. 4 is a diagram showing an example of a medical document created by the general-purpose document order component 12. FIG. 5 is an example of a screen used for editing the order input screen. FIG. 6 is a diagram showing an example of operations that can be performed using the window of FIG. FIG. 7 is a diagram showing another example of a screen related to customization of the order input screen. FIG. 8 is a diagram showing another example of a screen related to customization of the order input screen. FIG. 9 is a diagram showing an example of a screen using a set of general-purpose document orders of the medical record input component 15. FIG. 10 is a diagram showing that the content input on the order input screen of the medical record input component 15 is also reflected on the medical record screen. FIG. 11 is a diagram showing an example of a screen that prompts the user to operate a periodic order.

FIG. 1 is a functional block diagram showing an example of a medical document creation system according to an embodiment. The medical document creation system 1 is a computer including a CPU (Central Processing Unit), and is typically a personal computer (PC), a workstation, or the like. The medical document creation system 1 includes a database 2 including a hard disk drive (HDD).

By installing a dedicated program in the medical document creation system 1 as a computer, it is possible to realize various functions of the medical document creation system. The program can be written and distributed on a recording medium such as a CD-ROM.

The medical document creation system 1 includes a control unit 11, a general-purpose document order component 12, a general-purpose document order set component 13, a general-purpose document order master component 14, a chart input component 15, a user interface 16, and a communication interface (IF) 17. Of these, the user interface 16 includes a keyboard, a mouse, a display capable of displaying a plurality of screens, and the like. The communication interface is connected to a LAN (Local Area Network).

The general-purpose document order component 12, the general-purpose document order set component 13, the general-purpose document order master component 14, and the medical record input component 15 are, for example, program components and can include a sequence of instructions written in a predetermined programming language.

The general-purpose document order component 12 includes a database (DB) search unit 121, an order input screen editing unit 122, a document creation unit 123, and a DB registration unit 124 as functional blocks. The DB search unit 121 searches the database 2 based on the message from the order input screen editing unit 122, and acquires necessary information.

The order input screen editing unit 122 arranges an input control selected from a plurality of input controls prepared in advance on the initial screen, and customizes the order input screen. The initial screen is, for example, a window on which a plurality of input controls are arranged, as shown in FIG. 6 (described later).

The document creation unit 123 creates a medical document that reflects the contents input on the order input screen including a plurality of items and the information acquired from the database 2.

The DB registration unit 124 registers the created order input screen and medical documents in the database 2.
The general-purpose document order set component 13 includes a DB search unit 131, a set creation unit 132, and a DB registration unit 133 as functional blocks. The DB search unit 131 acquires necessary information from the database 2 in response to a request from the set creation unit 132. The set creation unit 132 groups a plurality of order information based on a predetermined standard, and reflects the grouped order information on the order input screen. The DB registration unit 133 registers the grouped order information in the database 2.

The general-purpose document order master component 14 includes a DB search unit 141, a master editing unit 142, and a DB registration unit 143. Of these, the master editorial unit 142 registers information such as an input screen of the general-purpose document order component 12, the type of document to be created, and the definition of information to be cited. These registered information are stored in the database 2.

The medical record input component 15 includes a DB search unit 151, a medical record editing unit 152, and a DB registration unit 153 as functional blocks. The DB search unit 151 acquires necessary data from the database 2 in response to a request from the medical record editing unit 152. The medical record editorial unit 152 creates an electronic medical record based on the acquired information. The DB registration unit 153 registers the created electronic medical record in the database 2.

The control unit 11 includes a display control unit 111 and a communication control unit 112 as functional blocks. The display control unit 111 displays various screens and windows such as an order input screen and a document creation window on the display of the user interface 16. The communication control unit 112 controls communication in the local area via the LAN.

Control unit 11, general-purpose document order component 12, general-purpose document order set component 13, general-purpose document order master component 14, chart input component 15, user interface 16, communication interface (IF) 17, DB search unit 121, order input screen editing Unit 122, document creation unit 123, DB registration unit 124, DB search unit 131, set creation unit 132, DB registration unit 133, DB search unit 141, master editorial unit 142, DB registration unit 143, DB search unit 151, chart editing Each processing function executed by the unit 152, the DB registration unit 153, the display control unit 111, and the communication control unit 112 is recorded in the storage circuit in the form of a program that can be executed by a computer. The processing circuit is a processor that realizes the function corresponding to each program by reading the program from the storage circuit and executing it. In other words, the processing circuit in the state where each program is read has each function shown in FIG.

The word "processor" refers to, for example, a CPU, a GPU (Graphics Processing Unit), or an application specific integrated circuit (ASIC), a programmable logic device (for example, a simple programmable logic device). : SPLD), Complex Programmable Logic Device (CPLD), and Field Programmable Gate Array (FPGA)).

The processor realizes the function by reading and executing the program stored in the storage circuit. Instead of storing the program in the storage circuit, the program may be directly embedded in the circuit of the processor. In this case, the processor realizes the function by reading and executing the program embedded in the circuit.

The database 2 holds patient information 21, disease name information 22, vital information 23, test result information 24, order information 25, master information 26, general-purpose document order set master 27, and general-purpose document order periodic information 28. The database 2 also holds time-series information such as past order information of patients.

The patient information 21 includes information such as an ID (IDentification), name, date of birth, and gender for each patient. The disease name information 22 is information including individual disease names. The vital information 23 is information including measurement results such as body temperature and blood pressure for each patient. The test result information 24 is information including test results for each patient. The order information 25 is order information for a general-purpose document order. The master information 26 is master information for editing a general-purpose document order. Next, a plurality of embodiments will be described based on the above configuration.

[First Embodiment]
FIG. 2 is a flowchart showing a processing procedure for inputting a general-purpose document order in the medical document creation system 1 of FIG. In FIG. 2, a user such as a doctor activates the medical record input component 15 and selects a patient on the displayed window (step S1). Next, the user clicks a predetermined area of the medical record input component to activate the general-purpose document order component 12 (step S2). The activated general-purpose document order component 12 displays a window as shown in FIG. 3 on the display of the user interface 16.

FIG. 3 is a diagram showing an example of an order input screen. As an example, FIG. 3 shows an example of a screen (order palette) used for creating a nutritional guidance order. The user inputs the order contents related to, for example, the nutritional guidance order to the patient selected in step S1 using this order input screen (step S3).

For example, [Diabetes A] is selected in the diet column that can be selected in the drop-down list, and the permissible amount suitable for the patient is specified in grams for each item such as calorie, protein, and lipid. Diabetes and hyperlipidemia are checked (selected) in areas where the scroll bar can be slid to select the disease name, indicating that the patient has these diseases.

When the necessary information is input, the user then presses (clicks) the [Create] button on the window shown in FIG. 3 on the screen. Then, the general-purpose document order component 12 starts creating a document (step S4).

Finally, the general-purpose document order component 12 acquires patient information 21, disease name information 22, vital information 23, and test result information 24 from the database 2 in addition to the information input in step S3, and is shown in FIG. Create a document that can be used (step S5).

FIG. 4 is a diagram showing an example of a medical document created by the general-purpose document order component 12. In FIG. 4, for example, in the column of indicated nutrients, the information input on the order input screen of FIG. 3 is quoted, such as calorific value (1500 kcal), protein (70 g), and lipid (40 g). In addition, the values read from the database 2 are cited in columns such as patient number, name, vitals, and test value. Through the above process, a standard medical document is created.

By the way, there is a need to customize the order input screen (Fig. 3). Next, we will disclose technologies that can meet such needs.

FIG. 5 is an example of a screen used for editing the order input screen. The screen of FIG. 5 is drawn by the general-purpose document order master component 14. This screen is referred to as, for example, [general purpose order pallet maintenance] in the embodiment.

The user can create an order input screen for each type of order, such as medication guidance, nutritional guidance, etc., using the window of FIG. This function is mainly realized by the program routine of the general-purpose document order master component 14.

In the control field on the right side of the window of FIG. 5, a plurality of items for specifying an input method on the order input screen are provided. As shown in FIG. 6, desired input controls (text box, date text box, pull-down list, check box, etc.) are arranged on the screen by dragging and dropping (D & D) or the like from this control field, and input items are input. By registering information such as input candidates according to the input control for each, it is possible to create an input screen for a general-purpose document order.

Further, the window of FIG. 5 (FIG. 6) has a detailed setting field. This detailed setting field is provided to set the property of each input item and to specify the reflection position of the document. The input screen of the general-purpose document order component 12, the type of the document to be created, and the definition of the information to be cited are registered in the database 2 by the general-purpose document order master component 14.

In addition, a document that reflects the input contents can be associated, and the reflection position in the document can be defined for each input control. The position to be reflected may be defined as a character string to be replaced in the case of word processing software, or as a cell position (such as "A1") in the case of form software.

As described above, according to the first embodiment, the order input screen can be arbitrarily customized according to the purpose, and the contents input on the order input screen can be automatically quoted in the created document. can. Since the existing medical document creation system does not have a function of modifying the order input screen according to the user's intention, it is not possible to cite data of items that are not in the predetermined items in the medical document. Therefore, it is necessary to start word processing software and form software separately and edit the information that cannot be quoted directly on these applications.

On the other hand, according to the embodiment, the input items arranged on the order input screen can be arbitrarily customized according to the user's request and the purpose of the document. Therefore, according to the first embodiment, it is possible to provide a medical document creation system and a medical document creation program in which the order input screen can be easily customized.

[Second Embodiment]
7 and 8 are diagrams showing other examples of screens related to customization of the order input screen. FIG. 7 shows an example of a window generated by the medical record input component 15. For example, patients with chronic diseases often have repeated recurrences of similar symptoms. Therefore, by copying the past general-purpose document order as shown in FIG. 8, data input can be saved.

As shown in FIG. 8, the portion surrounded by the frame of the general-purpose document order indicates a case where the document order becomes the same as in the past due to recurrence or the like. In such a case, the past order information of the same patient is acquired from the database 2, and the value of the item on the order input screen is initialized by the acquired order information. In other words, by copying the past data and substituting it as the initial value of each item on the order input screen, the same medical document is issued for the same symptom. Further, the copied general-purpose document order can be edited again by the general-purpose document order component 12. This makes it possible to improve the efficiency of creating medical documents with less effort.

[Third Embodiment]
FIG. 9 is a diagram showing an example of a screen using a set of general-purpose document orders of the medical record input component 15. The general-purpose document order input in the first embodiment can be registered in the general-purpose document order set master 27 by the general-purpose document order set component 13. The set (grouped) general-purpose document order can be easily input by a click operation or the like. In FIG. 9, for example, when the [Patience] button is clicked, the corresponding order information is opened.

As shown in FIG. 10, the content input on the order input screen of the medical record input component 15 is also reflected on the medical record screen depending on the setting. On the contrary, it is also possible to prevent it from being reflected by setting.

[Fourth Embodiment]
FIG. 11 is a diagram showing an example of a screen that prompts the user to operate a periodic order. In this embodiment, the general-purpose document order component 12 acquires the patient's past order information regarding the periodically executed order from the database 2. Then, after a certain period of time (for example, weekly or monthly) has elapsed, the user is prompted to input to the order input screen. That is, for example, a general-purpose document order to be periodically executed in combination with a function of basic Do / periodic Do known in advance is registered in the general-purpose document order periodic information 28 for each patient. By doing so, the input of the order is guided when the corresponding general-purpose document order is not input for a certain period of time. This makes it possible to prevent omission of order input.

Each function according to each embodiment described above can also be realized by installing a program that executes the process on a computer and expanding these on a memory. Programs that allow a computer to perform the procedure are stored on a computer-readable recording medium such as a magnetic disk (floppy (registered trademark) disk, hard disk, etc.), optical disk (CD-ROM, DVD, etc.), semiconductor memory, etc. It is also possible to distribute it.

Although some embodiments of the present invention have been described, these embodiments are presented as examples and are not intended to limit the scope of the invention. These novel embodiments can be implemented in various other embodiments, and various omissions, replacements, and changes can be made without departing from the gist of the invention. These embodiments and modifications thereof are included in the scope and gist of the invention, and are also included in the scope of the invention described in the claims and the equivalent scope thereof.

1 ... Medical document creation system, 2 ... Database, 11 ... Control unit, 12 ... General-purpose document order component, 13 ... General-purpose document order set component, 14 ... General-purpose document order master component, 15 ... Carte input component, 16 ... User interface, 17 ... Communication interface, 21 ... Patient information, 22 ... Disease name information, 23 ... Vital information, 24 ... Test result information, 25 ... Order information, 26 ... Master information, 27 ... General-purpose document order set master, 28 ... General-purpose document order regular Information, 111 ... Display control unit, 112 ... Communication control unit, 121 ... DB search unit, 122 ... Order input screen editing unit, 123 ... Document creation unit, 124 ... DB registration unit, 131 ... DB search unit, 132 ... Set creation Department 133 ... DB registration department, 141 ... DB search department, 142 ... Master editorial department, 143 ... DB registration department, 151 ... DB search department, 152 ... Carte editorial department, 153 ... DB registration department

Claims (10)

Display and
A database that holds information unique to each patient,
A medical document that reflects the content input on the order input screen, which is an order input screen in which data suitable for the patient is input by the user for each item and includes a plurality of items, and the information acquired from the database. Document creation method to create and
An input control selected from a plurality of input controls prepared in advance is arranged on the initial screen, and the order input screen is provided with an order input screen editing means for customizing each order type according to the application.
The order input screen includes an input control for inputting whether or not to cite the information to be cited as a definition of information to be quoted from the database.
The information to be quoted, the by document creation means Ru are reflected in the medical document is retrieved from the database, the medical documentation system. The medical document creation system according to claim 1, wherein the order input screen editing means can customize the order input screen while confirming the arrangement of the selected input control on the display unit. The database holds the patient's past order information and
The medical document creation according to claim 1, wherein the document creation means acquires the past order information of the patient from the database and initializes the value of the item on the order input screen with the acquired order information. system. 3. The document creation means obtains the patient's past order information regarding a periodically executed order from the database, and prompts the user to input to the order input screen after a lapse of a certain period of time. The medical document creation system described in. The medical document creation system according to claim 1, wherein the document creation means groups a plurality of order information based on a predetermined standard and reflects the grouped order information on the order input screen. A program executed by a computer having a display unit, the computer.
A database that holds information unique to each patient,
A medical document that reflects the content input on the order input screen, which is an order input screen in which data suitable for the patient is input by the user for each item and includes a plurality of items, and the information acquired from the database. Document creation method to create and
An input control selected from a plurality of input controls prepared in advance is arranged on the initial screen, and the order input screen is made to function as an order input screen editing means for customizing each order type according to the application .
The order input screen includes an input control for inputting whether or not to cite the information to be cited as a definition of information to be quoted from the database.
The information to be quoted, is acquired from the database by the document creation unit Ru is reflected in the medical document, medical document creation program. The medical document creation program according to claim 6, wherein the order input screen editing means makes it possible to customize the order input screen while confirming the arrangement of the selected input control in the display unit. The database holds the patient's past order information and
The medical document creation according to claim 6, wherein the document creation means acquires the past order information of the patient from the database and initializes the value of the item on the order input screen with the acquired order information. program. 8. The document-creating means obtains the patient's past order information regarding a periodically executed order from the database, and prompts the user to input to the order input screen after a lapse of a certain period of time. The medical document creation program described in. The medical document creation program according to claim 6, wherein the document creation means groups a plurality of order information based on a predetermined standard and reflects the grouped order information on the order input screen.

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